Provider Demographics
NPI:1275803231
Name:LEAVENS, EMILY E (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:E
Last Name:LEAVENS
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:PO BOX 468
Mailing Address - Street 2:
Mailing Address - City:SKOWHEGAN
Mailing Address - State:ME
Mailing Address - Zip Code:04976-0468
Mailing Address - Country:US
Mailing Address - Phone:207-858-8353
Mailing Address - Fax:207-474-9261
Practice Address - Street 1:57 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:SKOWHEGAN
Practice Address - State:ME
Practice Address - Zip Code:04976-1403
Practice Address - Country:US
Practice Address - Phone:207-474-7000
Practice Address - Fax:207-858-4772
Is Sole Proprietor?:No
Enumeration Date:2012-01-09
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP2229235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1275803231Medicaid