Provider Demographics
NPI:1356615744
Name:LEIS, ANNA CHRISTINE (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:ANNA
Middle Name:CHRISTINE
Last Name:LEIS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MS
Other - First Name:ANNA
Other - Middle Name:CHRISTINE
Other - Last Name:CORDERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:2752 HILLVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-1078
Mailing Address - Country:US
Mailing Address - Phone:310-728-9298
Mailing Address - Fax:
Practice Address - Street 1:1125 MISSOURI ST STE 304A
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-6064
Practice Address - Country:US
Practice Address - Phone:925-672-9440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18515235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist