Provider Demographics
NPI:1831668391
Name:SHANKS, LESLEY (MA, CF-SLP)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:
Last Name:SHANKS
Suffix:
Gender:F
Credentials:MA, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 W SHOREWOOD CT
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525-9542
Mailing Address - Country:US
Mailing Address - Phone:815-517-8235
Mailing Address - Fax:
Practice Address - Street 1:4812 PFEIFFER RD
Practice Address - Street 2:
Practice Address - City:BARTONVILLE
Practice Address - State:IL
Practice Address - Zip Code:61607-2647
Practice Address - Country:US
Practice Address - Phone:309-697-0880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242005099235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty