Provider Demographics
NPI:1689898371
Name:LEIDHOLT, STACY (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:LEIDHOLT
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16870 91ST AVE N APT 218
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-5485
Mailing Address - Country:US
Mailing Address - Phone:763-486-3584
Mailing Address - Fax:
Practice Address - Street 1:300 COON RAPIDS BLVD NW STE 200
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5645
Practice Address - Country:US
Practice Address - Phone:763-767-0854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7946235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist