Provider Demographics
NPI:1093181257
Name:JOHNSON, LESLIE ANN (MS)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:A
Other - Last Name:CLARKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:245 N 3RD E
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-2734
Mailing Address - Country:US
Mailing Address - Phone:208-587-8255
Mailing Address - Fax:
Practice Address - Street 1:13176 W PERSIMMON LN STE 120
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-5027
Practice Address - Country:US
Practice Address - Phone:208-376-3591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-3063235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist