Provider Demographics
NPI:1003906231
Name:SEVILLENA, LESLEY S (PT)
Entity Type:Individual
Prefix:MRS
First Name:LESLEY
Middle Name:S
Last Name:SEVILLENA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LESLEY
Other - Middle Name:
Other - Last Name:BENVENISTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11 EAGLE ROCK AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:EAST HANOVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07936-3167
Mailing Address - Country:US
Mailing Address - Phone:973-887-9000
Mailing Address - Fax:973-887-3816
Practice Address - Street 1:311 NORTH ST STE 304
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605
Practice Address - Country:US
Practice Address - Phone:914-448-4777
Practice Address - Fax:914-448-4788
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01135700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist