Provider Demographics
NPI:1417605536
Name:SPEED, LORI LESHAN
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:LESHAN
Last Name:SPEED
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:PO BOX 3862
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32721-3862
Mailing Address - Country:US
Mailing Address - Phone:336-521-3222
Mailing Address - Fax:336-649-4120
Practice Address - Street 1:PO BOX 3862
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32721-3862
Practice Address - Country:US
Practice Address - Phone:336-521-3222
Practice Address - Fax:336-521-3222
Is Sole Proprietor?:No
Enumeration Date:2022-03-17
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-23127101YM0800X
NC17487101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020986Medicaid