MEDICARE: LEIANA JAE THOMAS GARY

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	146004351	IL

General Provider Information

NPI Number	:	1730341561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEIANA JAE THOMAS GARY

Provider Business Mailing Address
First Line	:	7937 S EVANS
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7937 S EVANS AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-3906
Country	:	US
Telephone Number	:	773-368-6610
Fax Number	:	773-651-0636

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

Provider Enumeration Date	:	07/02/2008
Last Update Date	:	07/02/2008

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