Provider Demographics
NPI:1750604740
Name:GROSS, LESLIE ANN (MS CCC/SLP)
Entity type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:ANN
Last Name:GROSS
Suffix:
Gender:F
Credentials:MS CCC/SLP
Other - Prefix:MISS
Other - First Name:LESLIE
Other - Middle Name:ANN
Other - Last Name:BURRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC/SLP
Mailing Address - Street 1:CMR 402
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180-3460
Mailing Address - Country:US
Mailing Address - Phone:49636-399-4187
Mailing Address - Fax:
Practice Address - Street 1:CMR 402
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180-3460
Practice Address - Country:US
Practice Address - Phone:49636-399-4187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-05
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202003951235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist