Provider Demographics
NPI:1205967577
Name:MELLOR, LESLEY (MS CCC-SP)
Entity type:Individual
Prefix:
First Name:LESLEY
Middle Name:
Last Name:MELLOR
Suffix:
Gender:F
Credentials:MS CCC-SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14508 W CLARENDON AVE
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-8243
Mailing Address - Country:US
Mailing Address - Phone:623-256-4880
Mailing Address - Fax:
Practice Address - Street 1:11047 N 79TH PL
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-5598
Practice Address - Country:US
Practice Address - Phone:602-619-6061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP4309235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ881658Medicaid