Provider Demographics
NPI:1710543764
Name:SUMMERS, LESLEY NICOLE (MAT, MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:NICOLE
Last Name:SUMMERS
Suffix:
Gender:F
Credentials:MAT, MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1419 HUBBARD ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206-4533
Mailing Address - Country:US
Mailing Address - Phone:904-431-7276
Mailing Address - Fax:904-456-0838
Practice Address - Street 1:1419 HUBBARD ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-4533
Practice Address - Country:US
Practice Address - Phone:904-431-7276
Practice Address - Fax:904-456-0838
Is Sole Proprietor?:No
Enumeration Date:2019-05-15
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA16358208000000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics