Provider Demographics
NPI:1558050005
Name:BUTCHER, LESLIE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:BUTCHER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2406 ELKHORN TER
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-1734
Mailing Address - Country:US
Mailing Address - Phone:716-316-2571
Mailing Address - Fax:
Practice Address - Street 1:2775 CRUSE RD STE 2002
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-7147
Practice Address - Country:US
Practice Address - Phone:770-289-0308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-02
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP09806235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty