Provider Demographics
NPI:1700518495
Name:DAVIS, LEANNE KRISTIN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LEANNE
Middle Name:KRISTIN
Last Name:DAVIS
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 1:1435 VZCR 1116
Mailing Address - Street 2:
Mailing Address - City:FRUITVALE
Mailing Address - State:TX
Mailing Address - Zip Code:75127-3474
Mailing Address - Country:US
Mailing Address - Phone:818-389-5794
Mailing Address - Fax:
Practice Address - Street 1:1435 VZCR 1116
Practice Address - Street 2:
Practice Address - City:FRUITVALE
Practice Address - State:TX
Practice Address - Zip Code:75127-3474
Practice Address - Country:US
Practice Address - Phone:818-389-5794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110541235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist