Provider Demographics
NPI:1750757217
Name:DEDOMINIC, LESLIE M (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:M
Last Name:DEDOMINIC
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 1:2195 CLUB CENTER DR
Mailing Address - Street 2:SUITE G
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-4170
Mailing Address - Country:US
Mailing Address - Phone:909-835-1887
Mailing Address - Fax:909-835-1858
Practice Address - Street 1:2195 CLUB CENTER DR
Practice Address - Street 2:SUITE G
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-4170
Practice Address - Country:US
Practice Address - Phone:909-835-1887
Practice Address - Fax:909-835-1858
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22261235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA57857OtherCALIFORNIA CHILDREN'S SERVICES