Provider Demographics
NPI:1033310990
Name:DEVINE, LESLIE
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:
Last Name:DEVINE
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:LESLIE
Other - Middle Name:SUSAN
Other - Last Name:HERZIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2 LYNDON LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11720-1212
Mailing Address - Country:US
Mailing Address - Phone:631-736-6849
Mailing Address - Fax:
Practice Address - Street 1:35 LONGWOOD RD
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953-2045
Practice Address - Country:US
Practice Address - Phone:631-924-0008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009944235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY009944OtherLICENSE