Provider Demographics
NPI:1073080883
Name:DISMUKES, LEIGH ALICE (OTR)
Entity Type:Individual
Prefix:
First Name:LEIGH
Middle Name:ALICE
Last Name:DISMUKES
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 SAMUEL BLVD APT 2Q
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-3048
Mailing Address - Country:US
Mailing Address - Phone:972-965-5923
Mailing Address - Fax:
Practice Address - Street 1:3535 N HALL ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-5416
Practice Address - Country:US
Practice Address - Phone:214-559-7015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105700225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist