=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275933632
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LESLIE REID M.A. CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2014
-----------------------------------------------------
Last Update Date | 04/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6506 STATE ROUTE 229
-----------------------------------------------------
City | MARENGO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43334-9738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-602-2969
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 890 W 4TH ST
-----------------------------------------------------
City | ONTARIO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44906-2565
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-680-2852
-----------------------------------------------------
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 | COND.2015024-SP
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SP.11734
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------