Provider Demographics
NPI:1972760015
Name:BLACK, LESLIE C (MS,CCC/SLP)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:C
Last Name:BLACK
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 1:2460 17TH AVE STE 1041
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-1860
Mailing Address - Country:US
Mailing Address - Phone:831-204-1908
Mailing Address - Fax:801-942-5955
Practice Address - Street 1:1421 WHISPERING PINES DRIVE
Practice Address - Street 2:
Practice Address - City:SCOTTS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95066
Practice Address - Country:US
Practice Address - Phone:831-204-1908
Practice Address - Fax:801-942-5955
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13417235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist