Provider Demographics
NPI:1346788668
Name:SHUKLA, LEAH (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:SHUKLA
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:
Other - Last Name:GROSSMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:324 ARNETT AVE
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-2104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 MARCH ST
Practice Address - Street 2:
Practice Address - City:SANTA PAULA
Practice Address - State:CA
Practice Address - Zip Code:93060
Practice Address - Country:US
Practice Address - Phone:805-525-7134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 22718235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASP 22718OtherSTATE OF CA DEPARTMENT OF CONSUMER AFFAIRS- SPEECH LANGUAGE PATHOLOGIST
12135610OtherASHA, CERTIFICATE OF CLINICAL COMPETENCE