Provider Demographics
NPI:1598430654
Name:LESLIE, TINA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:LESLIE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15249 BULL RUN RD
Mailing Address - Street 2:
Mailing Address - City:COATSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63535-4200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21701 US HIGHWAY 63
Practice Address - Street 2:
Practice Address - City:QUEEN CITY
Practice Address - State:MO
Practice Address - Zip Code:63561-2171
Practice Address - Country:US
Practice Address - Phone:660-956-4125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist