Provider Demographics
NPI:1184091886
Name:LEATHERBURY, PATRICIA (MS/CCC-SLP)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:LEATHERBURY
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 1:753 NW FORT SILL BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-5421
Mailing Address - Country:US
Mailing Address - Phone:580-467-1990
Mailing Address - Fax:
Practice Address - Street 1:753 NW FORT SILL BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-5421
Practice Address - Country:US
Practice Address - Phone:580-467-1990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-28
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3244235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist