Provider Demographics
NPI:1013251875
Name:LEISING, GINA (MAT, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:LEISING
Suffix:
Gender:F
Credentials:MAT, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6126 W PARK VIEW LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-2701
Mailing Address - Country:US
Mailing Address - Phone:623-877-7547
Mailing Address - Fax:
Practice Address - Street 1:10640 N 28TH DR
Practice Address - Street 2:C-104
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4527
Practice Address - Country:US
Practice Address - Phone:602-626-8851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP8079235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist