Provider Demographics
NPI:1003396896
Name:NICHOLS, LEAH REILLY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:REILLY
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3044 DUE WEST RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-2125
Mailing Address - Country:US
Mailing Address - Phone:770-443-9672
Mailing Address - Fax:
Practice Address - Street 1:3044 DUE WEST ROAD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-3015
Practice Address - Country:US
Practice Address - Phone:770-443-9672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP010245235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist