Provider Demographics
NPI:1417975665
Name:PETERSON, LESLIE DANIELLE (MSCCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:LESLIE
Middle Name:DANIELLE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MSCCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 NE 5TH ST
Mailing Address - Street 2:
Mailing Address - City:HAVANA
Mailing Address - State:FL
Mailing Address - Zip Code:32333-1765
Mailing Address - Country:US
Mailing Address - Phone:850-294-1199
Mailing Address - Fax:
Practice Address - Street 1:303 NE 5TH ST
Practice Address - Street 2:
Practice Address - City:HAVANA
Practice Address - State:FL
Practice Address - Zip Code:32333-1765
Practice Address - Country:US
Practice Address - Phone:850-294-1199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 8226235Z00000X
GASLP007123235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist