Provider Demographics
NPI:1043220429
Name:MATHEWS, LEESA L (PT)
Entity Type:Individual
Prefix:
First Name:LEESA
Middle Name:L
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3278 BECHELLI LN
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-2005
Mailing Address - Country:US
Mailing Address - Phone:530-223-9474
Mailing Address - Fax:530-223-6937
Practice Address - Street 1:2421 S YORK ST
Practice Address - Street 2:SUITE 14
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-8820
Practice Address - Country:US
Practice Address - Phone:918-683-8088
Practice Address - Fax:918-683-8093
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT2383225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK241431005Medicare ID - Type Unspecified