Provider Demographics
NPI:1740767318
Name:GOAD, LESLIE BROOKE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:BROOKE
Last Name:GOAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2014 WOODBOURNE AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-1910
Mailing Address - Country:US
Mailing Address - Phone:270-869-7405
Mailing Address - Fax:
Practice Address - Street 1:13010 EASTGATE PARK WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-3984
Practice Address - Country:US
Practice Address - Phone:502-244-1210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY173569235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist