Provider Demographics
NPI:1659784601
Name:LETSON, STACIE
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:LETSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 COMPASS RD
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-8001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:CA
Practice Address - Zip Code:94706-2214
Practice Address - Country:US
Practice Address - Phone:510-384-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-07
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ6657235Z00000X
CA25177235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist