Provider Demographics
NPI:1013288828
Name:BLACK, LESLIE LEIGH
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:LEIGH
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:LESLIE
Other - Middle Name:LEIGH
Other - Last Name:RENFRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:627 MIDDLETON RD
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MS
Mailing Address - Zip Code:38967-2021
Mailing Address - Country:US
Mailing Address - Phone:662-417-1773
Mailing Address - Fax:
Practice Address - Street 1:627 MIDDLETON RD
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MS
Practice Address - Zip Code:38967-2021
Practice Address - Country:US
Practice Address - Phone:662-417-1773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3010235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist