Provider Demographics
NPI:1922245802
Name:EVANS, LEILA
Entity Type:Individual
Prefix:
First Name:LEILA
Middle Name:
Last Name:EVANS
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 1:318 W PIKE ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-3234
Mailing Address - Country:US
Mailing Address - Phone:678-377-2833
Mailing Address - Fax:678-377-2882
Practice Address - Street 1:318 W PIKE ST
Practice Address - Street 2:SUITE 104
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-3234
Practice Address - Country:US
Practice Address - Phone:678-377-2833
Practice Address - Fax:678-377-2882
Is Sole Proprietor?:No
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006940235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA852476861AMedicaid