Provider Demographics
NPI:1982808945
Name:MCCULLY, LESLI BACON
Entity type:Individual
Prefix:
First Name:LESLI
Middle Name:BACON
Last Name:MCCULLY
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 1:1696 CARRUTHERS PL
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38112-5208
Mailing Address - Country:US
Mailing Address - Phone:901-604-7611
Mailing Address - Fax:
Practice Address - Street 1:610 S AVALON ST
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4109
Practice Address - Country:US
Practice Address - Phone:870-400-3481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP8000235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist