Provider Demographics
NPI:1811482920
Name:MATHIS, LESLIE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:MATHIS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 WATKINS DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-5431
Mailing Address - Country:US
Mailing Address - Phone:334-701-0110
Mailing Address - Fax:
Practice Address - Street 1:100 WESTSIDE DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-1908
Practice Address - Country:US
Practice Address - Phone:334-793-2237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-30
Last Update Date:2018-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4004235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist