MEDICARE: LESA BLACK M.S. 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	LL00002959	WA

General Provider Information

NPI Number	:	1669702064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESA BLACK M.S. CCC-SLP

Provider Business Mailing Address
First Line	:	9725 SE 36TH ST
Second Line	:	SUITE 205
City	:	MERCER ISLAND
State	:	WA
Zip	:	98040-3841
Country	:	US
Telephone Number	:	206-232-2046
Fax Number	:	206-232-1096

Provider Business Practice Location Address
First Line	:	9725 SE 36TH ST
Second Line	:	SUITE 205
City	:	MERCER ISLAND
State	:	WA
Zip	:	98040-3841
Country	:	US
Telephone Number	:	206-232-2046
Fax Number	:	206-232-1096

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

Provider Enumeration Date	:	01/06/2010
Last Update Date	:	01/06/2010

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Directions to “ LESA BLACK M.S. CCC-SLP” Practice Location

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