Provider Demographics
NPI:1336326065
Name:LETT, ALICIA DAWN (MACCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:DAWN
Last Name:LETT
Suffix:
Gender:F
Credentials:MACCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 SOURWOOD LN
Mailing Address - Street 2:
Mailing Address - City:DANIELS
Mailing Address - State:WV
Mailing Address - Zip Code:25832
Mailing Address - Country:US
Mailing Address - Phone:304-763-3082
Mailing Address - Fax:
Practice Address - Street 1:105 ADAIR ST
Practice Address - Street 2:RALEIGH COUNTY BOARD OF EDUCATION
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801
Practice Address - Country:US
Practice Address - Phone:304-256-4500
Practice Address - Fax:304-256-4739
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV SLP 0580235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7402230000Medicaid