Provider Demographics
NPI:1912256157
Name:LEBAN, ETELLA (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ETELLA
Middle Name:
Last Name:LEBAN
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 1:415 LANGLEY AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11552-2316
Mailing Address - Country:US
Mailing Address - Phone:516-750-5847
Mailing Address - Fax:
Practice Address - Street 1:415 LANGLEY AVE
Practice Address - Street 2:
Practice Address - City:WEST HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11552-2316
Practice Address - Country:US
Practice Address - Phone:516-750-5847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-04
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017034-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist