Provider Demographics
NPI:1144452301
Name:LARGE, LESLIE SJAHN (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:SJAHN
Last Name:LARGE
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 1:453 MAKERS WAY
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-3363
Mailing Address - Country:US
Mailing Address - Phone:850-784-8060
Mailing Address - Fax:
Practice Address - Street 1:453 MAKERS WAY
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-3363
Practice Address - Country:US
Practice Address - Phone:850-784-8060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA2869235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist