MEDICARE: LESLIE CHIAVENTONE LOPEZ MS, CCC

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	SA15418	FL

General Provider Information

NPI Number	:	1265657316
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE CHIAVENTONE LOPEZ MS, CCC

Provider Business Mailing Address
First Line	:	PO BOX 917770
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32891-0001
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4202 E FOWLER AVE STOP PCD1017
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33620-3827
Country	:	US
Telephone Number	:	813-974-9844
Fax Number	:

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

Provider Enumeration Date	:	04/16/2007
Last Update Date	:	03/17/2018

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