Provider Demographics
NPI:1124448717
Name:SHOULDERS, LESLIE A (AUD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:SHOULDERS
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:ANN
Other - Last Name:TOWNSEND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:262-532-1560
Mailing Address - Fax:262-532-1380
Practice Address - Street 1:N84W16889 MENOMONEE AVE
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-2810
Practice Address - Country:US
Practice Address - Phone:262-532-1560
Practice Address - Fax:262-532-1380
Is Sole Proprietor?:No
Enumeration Date:2014-04-22
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2201001550231H00000X
WI692231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100092318Medicaid
VAP01415243Medicare PIN