Provider Demographics
NPI:1750426250
Name:LANDBERG, STACEY (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:LANDBERG
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 1:1716 N AVENUE 54
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-1105
Mailing Address - Country:US
Mailing Address - Phone:626-922-5275
Mailing Address - Fax:
Practice Address - Street 1:1716 N AVENUE 54
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-1105
Practice Address - Country:US
Practice Address - Phone:626-922-5275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14535235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist