Provider Demographics
NPI:1225434814
Name:KELLY, LESLIE ANN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:LESLIE
Middle Name:ANN
Last Name:KELLY
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 1:2104 VISION DRIVE
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418
Mailing Address - Country:US
Mailing Address - Phone:561-312-1198
Mailing Address - Fax:
Practice Address - Street 1:11911 US HIGHWAY 1 STE 102
Practice Address - Street 2:
Practice Address - City:NORTH PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33408-2872
Practice Address - Country:US
Practice Address - Phone:561-694-7661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-10
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA880235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003260000Medicaid