Healthcare Provider Details

I. General information

NPI: 1588015200
Provider Name (Legal Business Name): LETICIA STONE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LETICIA PELLEGRINO

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5093 E BROOKFIELD DR
EAST LANSING MI
48823-4772
US

IV. Provider business mailing address

124 S LINCOLN ST
CHARLOTTE MI
48813-1316
US

V. Phone/Fax

Practice location:
  • Phone: 810-772-4089
  • Fax:
Mailing address:
  • Phone: 517-652-9700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801106524
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: