=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013439983
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEILA GREEN LITTLE SLP, CLT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2017
-----------------------------------------------------
Last Update Date | 07/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 750 COUNTY ROAD 413
-----------------------------------------------------
City | LLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78643-3142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-773-2284
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 750 COUNTY ROAD 413
-----------------------------------------------------
City | LLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78643-3142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 107919
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------