Provider Demographics
NPI:1871265637
Name:LEIS, LAURA SUSANA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:SUSANA
Last Name:LEIS
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 1:2641 NELSON CT
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33332-1835
Mailing Address - Country:US
Mailing Address - Phone:305-988-5705
Mailing Address - Fax:
Practice Address - Street 1:2641 NELSON CT
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33332-1835
Practice Address - Country:US
Practice Address - Phone:305-988-5705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10304235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist