Provider Demographics
NPI:1336665223
Name:LEEPER, MIA MALOTTE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:MALOTTE
Last Name:LEEPER
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 24TH ST
Mailing Address - Street 2:
Mailing Address - City:OCEANO
Mailing Address - State:CA
Mailing Address - Zip Code:93445-9164
Mailing Address - Country:US
Mailing Address - Phone:805-710-4634
Mailing Address - Fax:
Practice Address - Street 1:1770 24TH ST
Practice Address - Street 2:
Practice Address - City:OCEANO
Practice Address - State:CA
Practice Address - Zip Code:93445-9164
Practice Address - Country:US
Practice Address - Phone:805-710-4634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-22
Last Update Date:2024-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27126235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist