Provider Demographics
NPI:1023755295
Name:MIRE, LESLIE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:MIRE
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 1:401 BROADMOOR BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-5201
Mailing Address - Country:US
Mailing Address - Phone:337-521-7910
Mailing Address - Fax:337-521-7911
Practice Address - Street 1:401 BROADMOOR BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-5201
Practice Address - Country:US
Practice Address - Phone:337-521-7910
Practice Address - Fax:337-521-7911
Is Sole Proprietor?:No
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5702235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist