Provider Demographics
NPI:1487855474
Name:LATUS, STACY A (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:A
Last Name:LATUS
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 AUBURN CT
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189-8005
Mailing Address - Country:US
Mailing Address - Phone:414-604-7208
Mailing Address - Fax:414-604-7200
Practice Address - Street 1:10243 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2028
Practice Address - Country:US
Practice Address - Phone:414-604-7208
Practice Address - Fax:414-604-7200
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1966-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist