Provider Demographics
NPI:1477617132
Name:BLACKBURN, LEIGH (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LEIGH
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:LEIGH
Other - Middle Name:ANNE
Other - Last Name:BLACKBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, CCC-SLP
Mailing Address - Street 1:3752 ROSCOMMON S
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-4742
Mailing Address - Country:US
Mailing Address - Phone:706-364-1486
Mailing Address - Fax:706-364-1487
Practice Address - Street 1:601 N BELAIR SQ STE 19
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-4324
Practice Address - Country:US
Practice Address - Phone:706-364-1486
Practice Address - Fax:706-364-1487
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006107235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA238975068AMedicaid