Provider Demographics
NPI:1730695453
Name:LEAK, KARYN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KARYN
Middle Name:
Last Name:LEAK
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 1:550 ROUTE 45 N
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62858-2628
Mailing Address - Country:US
Mailing Address - Phone:618-665-3393
Mailing Address - Fax:618-665-4803
Practice Address - Street 1:550 ROUTE 45 N
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:IL
Practice Address - Zip Code:62858-2628
Practice Address - Country:US
Practice Address - Phone:618-665-3393
Practice Address - Fax:618-665-4803
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146009785235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist