Provider Demographics
NPI:1023130317
Name:LEISTEN, MARIE D (SLP)
Entity type:Individual
Prefix:MS
First Name:MARIE
Middle Name:D
Last Name:LEISTEN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 ONEIL WAY
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:MA
Mailing Address - Zip Code:01450-4228
Mailing Address - Country:US
Mailing Address - Phone:978-302-7819
Mailing Address - Fax:978-448-8626
Practice Address - Street 1:8 ONEIL WAY
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:MA
Practice Address - Zip Code:01450-4228
Practice Address - Country:US
Practice Address - Phone:978-302-7819
Practice Address - Fax:978-448-8626
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3122235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist