Provider Demographics
NPI:1598279903
Name:BALLINGER, LESLEY-ANN (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:LESLEY-ANN
Middle Name:
Last Name:BALLINGER
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 BOULDER ST
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-2251
Mailing Address - Country:US
Mailing Address - Phone:913-669-9315
Mailing Address - Fax:
Practice Address - Street 1:1200 HAWTHORN HOUSE DR
Practice Address - Street 2:
Practice Address - City:SHALIMAR
Practice Address - State:FL
Practice Address - Zip Code:32579-1168
Practice Address - Country:US
Practice Address - Phone:850-609-2550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA15835235Z00000X
14182258235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist