Provider Demographics
NPI:1265813695
Name:GREGORY, LESLIE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:GREGORY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10410 E 540
Mailing Address - Street 2:
Mailing Address - City:SALINA
Mailing Address - State:OK
Mailing Address - Zip Code:74365-2526
Mailing Address - Country:US
Mailing Address - Phone:918-521-7172
Mailing Address - Fax:918-868-5584
Practice Address - Street 1:499 W BOUNDRY
Practice Address - Street 2:275 W. MAIN
Practice Address - City:KANSAS
Practice Address - State:OK
Practice Address - Zip Code:74347-1662
Practice Address - Country:US
Practice Address - Phone:918-868-2567
Practice Address - Fax:918-868-5584
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2960235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100680100AMedicaid