Provider Demographics
NPI:1366892804
Name:BLACK, LEIGH ANN (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:LEIGH
Middle Name:ANN
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 1:97 COUNTY ROAD 591
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:AL
Mailing Address - Zip Code:35673
Mailing Address - Country:US
Mailing Address - Phone:256-566-1986
Mailing Address - Fax:
Practice Address - Street 1:300 HOSPITAL STREET
Practice Address - Street 2:
Practice Address - City:MOUTLON
Practice Address - State:AL
Practice Address - Zip Code:35650
Practice Address - Country:US
Practice Address - Phone:256-974-1146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3890235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist