Provider Demographics
NPI:1952060550
Name:HARGRAVE, LETANYA EDJUAND
Entity Type:Individual
Prefix:
First Name:LETANYA
Middle Name:EDJUAND
Last Name:HARGRAVE
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 1:350 KELLER PKWY
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-2249
Mailing Address - Country:US
Mailing Address - Phone:817-744-6128
Mailing Address - Fax:
Practice Address - Street 1:11773 BRAY BIRCH LN
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6780
Practice Address - Country:US
Practice Address - Phone:817-744-6128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX327752355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant