Provider Demographics
NPI:1699157842
Name:TATUM, LEIGH (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:LEIGH
Middle Name:
Last Name:TATUM
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 1:123 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32266-6017
Mailing Address - Country:US
Mailing Address - Phone:512-587-7468
Mailing Address - Fax:
Practice Address - Street 1:76 OSPREY VILLAGE DR
Practice Address - Street 2:
Practice Address - City:AMELIA ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32034-4962
Practice Address - Country:US
Practice Address - Phone:904-277-3337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13349235Z00000X
TX102704235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist