MEDICARE: DIANE GIBBONS LESKO SPEECH-LANGUAGE PATH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	03795	MD

General Provider Information

NPI Number	:	1093252892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE GIBBONS LESKO SPEECH-LANGUAGE PATH

Provider Business Mailing Address
First Line	:	4284 COATTAIL CT
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-5922
Country	:	US
Telephone Number	:	443-956-5120
Fax Number	:

Provider Business Practice Location Address
First Line	:	4284 COATTAIL CT
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-5922
Country	:	US
Telephone Number	:	443-956-5120
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2017
Last Update Date	:	01/31/2017

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Directions to “ DIANE GIBBONS LESKO SPEECH-LANGUAGE PATH” Practice Location

Language	Start Address	Practice Location

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