Provider Demographics
NPI:1124670773
Name:FAND, LEAH
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:FAND
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 1:1132 CLINTON ST APT 614
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-3228
Mailing Address - Country:US
Mailing Address - Phone:201-247-8302
Mailing Address - Fax:
Practice Address - Street 1:1132 CLINTON ST APT 614
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-3228
Practice Address - Country:US
Practice Address - Phone:201-247-8302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-14
Last Update Date:2019-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00664500235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2012478302OtherBLUE CROSS BLUE SHIELD