Provider Demographics
NPI:1770853871
Name:LEONARD, KIM H (MA/CCC/SLP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:H
Last Name:LEONARD
Suffix:
Gender:F
Credentials:MA/CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-1646
Mailing Address - Country:US
Mailing Address - Phone:631-757-1158
Mailing Address - Fax:
Practice Address - Street 1:51 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-2231
Practice Address - Country:US
Practice Address - Phone:631-471-0354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY58007045235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist