Provider Demographics
NPI:1881471001
Name:HANCOCK, LESLIE RYAN
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:RYAN
Last Name:HANCOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:RYAN
Other - Last Name:BLACKLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1604 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62951-1950
Mailing Address - Country:US
Mailing Address - Phone:618-521-3728
Mailing Address - Fax:
Practice Address - Street 1:442 COMFORT DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-4927
Practice Address - Country:US
Practice Address - Phone:618-364-0482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146016389235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist