Provider Demographics
NPI:1376879668
Name:LEIBEL, TARA (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:LEIBEL
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 HOPEWELL PLANTATION DR
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-3657
Mailing Address - Country:US
Mailing Address - Phone:248-981-6590
Mailing Address - Fax:
Practice Address - Street 1:2655 HOPEWELL PLANTATION DR
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-3657
Practice Address - Country:US
Practice Address - Phone:248-981-6590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-21
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008661235Z00000X
IL146.010061235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist