Provider Demographics
NPI:1790038073
Name:HEITBRINK, LESLIE (SLP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:HEITBRINK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1498 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45331-2454
Mailing Address - Country:US
Mailing Address - Phone:937-548-2317
Mailing Address - Fax:937-548-3055
Practice Address - Street 1:1498 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-2454
Practice Address - Country:US
Practice Address - Phone:937-548-2317
Practice Address - Fax:937-548-3055
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH9446235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist