Provider Demographics
NPI:1467708818
Name:LEATHAM, MALLORY ANN (MS SLP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:ANN
Last Name:LEATHAM
Suffix:
Gender:F
Credentials:MS SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 E MALLORY ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-1447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2104 E MALLORY ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-1447
Practice Address - Country:US
Practice Address - Phone:480-748-0948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-02
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP7812235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist