Provider Demographics
NPI:1669647632
Name:LEBERG, SCOTT JEFFREY (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:JEFFREY
Last Name:LEBERG
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4721 BROOKSHIRE CT
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-9795
Mailing Address - Country:US
Mailing Address - Phone:715-423-1555
Mailing Address - Fax:
Practice Address - Street 1:4721 BROOKSHIRE CT
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-9795
Practice Address - Country:US
Practice Address - Phone:715-423-1555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2518-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist