Provider Demographics
NPI:1851767586
Name:LESLIE MCMULLEN
Entity Type:Organization
Organization Name:LESLIE MCMULLEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:321-287-0662
Mailing Address - Street 1:549 WOODLAND TERRACE BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-6765
Mailing Address - Country:US
Mailing Address - Phone:321-287-0662
Mailing Address - Fax:321-287-0662
Practice Address - Street 1:2701 N ROCKY POINT DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607
Practice Address - Country:US
Practice Address - Phone:321-287-0662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-17
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13731235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty