Healthcare Provider Details

I. General information

NPI: 1225991110
Provider Name (Legal Business Name): LEILA GHOSSOUB
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 FRANKLIN ST STE D
TENAFLY NJ
07670-2146
US

IV. Provider business mailing address

460 HEATH PL APT 46
HACKENSACK NJ
07601-1464
US

V. Phone/Fax

Practice location:
  • Phone: 201-525-8926
  • Fax:
Mailing address:
  • Phone: 201-315-1227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number41YS01362300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: