Provider Demographics
NPI:1104302595
Name:WILSON, LEANNA KATHERINE
Entity type:Individual
Prefix:MISS
First Name:LEANNA
Middle Name:KATHERINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28000 N NORTH VALLEY PKWY APT 1030
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-5803
Mailing Address - Country:US
Mailing Address - Phone:217-316-2035
Mailing Address - Fax:
Practice Address - Street 1:17100 E SHEA BLVD STE 600
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-6663
Practice Address - Country:US
Practice Address - Phone:480-837-4565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP11206235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty