Provider Demographics
NPI:1417439894
Name:LEAKE, KATHY SUZANNE (SPEECH THERAPIST)
Entity Type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:SUZANNE
Last Name:LEAKE
Suffix:
Gender:F
Credentials:SPEECH THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 BOXLEY LN
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:VA
Mailing Address - Zip Code:22960-1103
Mailing Address - Country:US
Mailing Address - Phone:540-672-7295
Mailing Address - Fax:
Practice Address - Street 1:158 PRIMARY SCHOOL DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:VA
Practice Address - Zip Code:22727-3008
Practice Address - Country:US
Practice Address - Phone:540-948-3781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-03
Last Update Date:2018-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2355S0801X, 235Z00000X
VA2203000317235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant