MEDICARE: TINA LESLIE CCC-SLP

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

General Provider Information

NPI Number	:	1598430654
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TINA LESLIE CCC-SLP

Provider Business Mailing Address
First Line	:	15249 BULL RUN RD
Second Line	:
City	:	COATSVILLE
State	:	MO
Zip	:	63535-4200
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	21701 US HIGHWAY 63
Second Line	:
City	:	QUEEN CITY
State	:	MO
Zip	:	63561-2171
Country	:	US
Telephone Number	:	660-956-4125
Fax Number	:

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

Provider Enumeration Date	:	08/11/2021
Last Update Date	:	08/11/2021

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Directions to “ TINA LESLIE CCC-SLP” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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