Provider Demographics
NPI:1932544491
Name:CHILDRESS, LESLIE RAE (SLP)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:RAE
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:RAE
Other - Last Name:ROERK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:1100 SHAWNEE RD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-3583
Mailing Address - Country:US
Mailing Address - Phone:419-999-2010
Mailing Address - Fax:419-999-6284
Practice Address - Street 1:1225 CORPORATE DR STE B
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:OH
Practice Address - Zip Code:43528-7701
Practice Address - Country:US
Practice Address - Phone:419-866-0555
Practice Address - Fax:419-866-0556
Is Sole Proprietor?:No
Enumeration Date:2013-05-09
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.13152235Z00000X
PASL012011235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA471551PNLMedicare PIN