Provider Demographics
NPI:1932513561
Name:WHITAKER, LESLIE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 CAMINO ALTO
Mailing Address - Street 2:SUITE E-3
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-2254
Mailing Address - Country:US
Mailing Address - Phone:415-205-1754
Mailing Address - Fax:
Practice Address - Street 1:131 CAMINO ALTO
Practice Address - Street 2:SUITE E-3
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-2254
Practice Address - Country:US
Practice Address - Phone:415-205-1754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11013235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist