=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932793296
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEIGH BALICE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2021
-----------------------------------------------------
Last Update Date | 02/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3620 LITTLEDALE RD
-----------------------------------------------------
City | KENSINGTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20895-3424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-301-8343
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 901 ORONOCO ST
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22314-2234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-902-0975
-----------------------------------------------------
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 | 09641
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------