Provider Demographics
NPI:1972643773
Name:GOOCH, LESLIE (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:GOOCH
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2272 GOLD RD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-5155
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2272 GOLD RD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34609-5155
Practice Address - Country:US
Practice Address - Phone:352-688-9773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA4615235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL282703OtherAVMED
FL885748200Medicaid
FL10621001OtherCITRUS HEALTHCARE