Provider Demographics
NPI:1124232210
Name:LEISTER, CARMIE A (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:CARMIE
Middle Name:A
Last Name:LEISTER
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 1:3162 JOHNSON FERRY RD
Mailing Address - Street 2:SUITE 260 #325
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-7604
Mailing Address - Country:US
Mailing Address - Phone:404-547-0825
Mailing Address - Fax:770-783-6618
Practice Address - Street 1:205 LAKEMONT DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-3203
Practice Address - Country:US
Practice Address - Phone:404-547-0825
Practice Address - Fax:770-783-6618
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005597235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist