Healthcare Provider Details

I. General information

NPI: 1710543764
Provider Name (Legal Business Name): LESLEY NICOLE SUMMERS MAT, MA, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2019
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1419 HUBBARD ST
JACKSONVILLE FL
32206-4533
US

IV. Provider business mailing address

1419 HUBBARD ST
JACKSONVILLE FL
32206-4533
US

V. Phone/Fax

Practice location:
  • Phone: 904-431-7276
  • Fax: 904-456-0838
Mailing address:
  • Phone: 904-431-7276
  • Fax: 904-456-0838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberSA16358
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA16358
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: