=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639094691
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BROOKLYN LESLIE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2026
-----------------------------------------------------
Last Update Date | 08/11/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9960 MAHAFFEY DR
-----------------------------------------------------
City | PALMETTO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34221-8169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-727-8842
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 IMPERIAL BLVD STE B1
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33803-4689
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-727-8842
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2355S0801X
-----------------------------------------------------
Taxonomy Name | Speech-Language Assistant
-----------------------------------------------------
License Number | 8990
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------