Provider Demographics
NPI:1194583666
Name:DETOTA, LESLIE SUZANNE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:SUZANNE
Last Name:DETOTA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:SUZANNE
Other - Last Name:PRITCHETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:117 STEEPLECHASE RUN
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-2627
Mailing Address - Country:US
Mailing Address - Phone:478-957-9003
Mailing Address - Fax:
Practice Address - Street 1:200 S KIMBERLY RD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-8721
Practice Address - Country:US
Practice Address - Phone:478-293-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP003705235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist