Provider Demographics
NPI:1306248539
Name:BRACKETT, LESLIE (MA)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:BRACKETT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:SAUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:926 NAPOLI DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-6442
Mailing Address - Country:US
Mailing Address - Phone:636-346-5890
Mailing Address - Fax:
Practice Address - Street 1:11960 WESTLINE INDUSTRIAL DR
Practice Address - Street 2:SUITE 201
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-3209
Practice Address - Country:US
Practice Address - Phone:314-819-0480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01755235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist