Provider Demographics
NPI:1205162971
Name:LEON, MICHELE DOMINGUEZ (SLP)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:DOMINGUEZ
Last Name:LEON
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 1:4921 SW 151ST TER
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-3621
Mailing Address - Country:US
Mailing Address - Phone:954-854-5369
Mailing Address - Fax:
Practice Address - Street 1:17670 NW 78TH AVE
Practice Address - Street 2:SUITE 113
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-3664
Practice Address - Country:US
Practice Address - Phone:305-512-5757
Practice Address - Fax:305-512-5755
Is Sole Proprietor?:No
Enumeration Date:2009-10-30
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10153235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist