Provider Demographics
NPI:1285379016
Name:NALL, MATTISON LEIGH
Entity type:Individual
Prefix:
First Name:MATTISON
Middle Name:LEIGH
Last Name:NALL
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 1:1700 JAKE ST UNIT 216
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-5912
Mailing Address - Country:US
Mailing Address - Phone:616-516-0454
Mailing Address - Fax:
Practice Address - Street 1:861 W MORSE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-3746
Practice Address - Country:US
Practice Address - Phone:407-637-2277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SI53532355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant