Provider Demographics
NPI:1962542530
Name:LEAHY, SANDRA LYNN (AUD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LYNN
Last Name:LEAHY
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3241 RACQUET CLUB DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-4708
Mailing Address - Country:US
Mailing Address - Phone:231-922-1500
Mailing Address - Fax:231-922-1502
Practice Address - Street 1:3241 RACQUET CLUB DR
Practice Address - Street 2:SUITE B
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4708
Practice Address - Country:US
Practice Address - Phone:231-922-1500
Practice Address - Fax:231-922-1502
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000288231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1601000288OtherLICENSE