Provider Demographics
NPI:1912185216
Name:BANE, LEIGH A (CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:LEIGH
Middle Name:A
Last Name:BANE
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 FAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840-1219
Mailing Address - Country:US
Mailing Address - Phone:304-574-1176
Mailing Address - Fax:
Practice Address - Street 1:111 FAYETTE AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840-1219
Practice Address - Country:US
Practice Address - Phone:304-574-1176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-08
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-0585235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist