Provider Demographics
NPI:1053647610
Name:MILLER, LESLIE MARIE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:MARIE
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:MARIE
Other - Last Name:PETERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4650 HARRISON BLVD
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4303
Mailing Address - Country:US
Mailing Address - Phone:801-475-3870
Mailing Address - Fax:801-475-3876
Practice Address - Street 1:1186 E 4600 S STE 320
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4303
Practice Address - Country:US
Practice Address - Phone:801-475-3870
Practice Address - Fax:801-475-3876
Is Sole Proprietor?:No
Enumeration Date:2009-11-02
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT374958-8019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant