Provider Demographics
NPI:1205532595
Name:MARTIN, LESLIE ANN (SLP- CCC)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:SLP- CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2503 ALLANJAY PL
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-2203
Mailing Address - Country:US
Mailing Address - Phone:818-606-4732
Mailing Address - Fax:
Practice Address - Street 1:2503 ALLANJAY PL
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-2203
Practice Address - Country:US
Practice Address - Phone:818-606-4732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP-6911235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist