Provider Demographics
NPI:1619306008
Name:LETT, BEVERLY (MA)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:LETT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27904 JOHN F KENNEDY DR
Mailing Address - Street 2:UNIT C
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-5873
Mailing Address - Country:US
Mailing Address - Phone:951-242-2196
Mailing Address - Fax:
Practice Address - Street 1:27904 JOHN F KENNEDY DR
Practice Address - Street 2:UNIT C
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-5873
Practice Address - Country:US
Practice Address - Phone:951-242-2196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22001045A235Z00000X
CASP 14169235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASP 14169OtherCALIFORNIA LICENSURE AS A SPEECH/LANGUAGE PATHOLOGIST
IN22001045AOtherINDIANA LICENSURE AS A SPEECH/LANGUAGE PATHOLOGIST