Basic Information
| Provider Information | |||||||||
| NPI: | 1972760015 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.S.,CCC/SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2460 17TH AVE STE 1041 | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950621860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8312041908 | ||||||||
| FaxNumber: | 8019425955 | ||||||||
| Practice Location | |||||||||
| Address1: | 1421 WHISPERING PINES DRIVE | ||||||||
| Address2: | |||||||||
| City: | SCOTTS VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8312041908 | ||||||||
| FaxNumber: | 8019425955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2008 | ||||||||
| LastUpdateDate: | 03/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 13417 | CA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.