Provider Demographics
NPI:1447875992
Name:LEGG, CARLY MARIE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:MARIE
Last Name:LEGG
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 1:472 AVENUE D
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17821-7629
Mailing Address - Country:US
Mailing Address - Phone:570-447-1216
Mailing Address - Fax:
Practice Address - Street 1:418 RAILROAD ST STE 102
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17821-1547
Practice Address - Country:US
Practice Address - Phone:330-536-3042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL015144235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist