Provider Demographics
NPI:1477862282
Name:LEONARD, ROBERTA MILLROD (MSCCC/LSP)
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:MILLROD
Last Name:LEONARD
Suffix:
Gender:F
Credentials:MSCCC/LSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 BROOKWOOD CT
Mailing Address - Street 2:
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-8518
Mailing Address - Country:US
Mailing Address - Phone:631-849-2236
Mailing Address - Fax:631-849-2236
Practice Address - Street 1:2 BROOKWOOD CT
Practice Address - Street 2:
Practice Address - City:ROCKY POINT
Practice Address - State:NY
Practice Address - Zip Code:11778-8518
Practice Address - Country:US
Practice Address - Phone:631-849-2236
Practice Address - Fax:631-849-2236
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001966235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY001966OtherLICENSE SPEECH PATHOLOGY