Healthcare Provider Details

I. General information

NPI: 1215848528
Provider Name (Legal Business Name): LEILA LAVENDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

899 244TH AVE SE
ENUMCLAW WA
98022-9998
US

IV. Provider business mailing address

141 LEOS PL APT A
ENUMCLAW WA
98022-9492
US

V. Phone/Fax

Practice location:
  • Phone: 360-802-7425
  • Fax:
Mailing address:
  • Phone: 760-625-7554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA.SP.70096502
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: