Provider Demographics
NPI:1669702064
Name:BLACK, LESA (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:LESA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9725 SE 36TH ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-3841
Mailing Address - Country:US
Mailing Address - Phone:206-232-2046
Mailing Address - Fax:206-232-1096
Practice Address - Street 1:9725 SE 36TH ST
Practice Address - Street 2:SUITE 205
Practice Address - City:MERCER ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98040-3841
Practice Address - Country:US
Practice Address - Phone:206-232-2046
Practice Address - Fax:206-232-1096
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00002959235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist