Provider Demographics
NPI:1083835128
Name:SHUTACK, LESLIE THERESE (LPTA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:THERESE
Last Name:SHUTACK
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6658 NW 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34475
Mailing Address - Country:US
Mailing Address - Phone:352-342-1679
Mailing Address - Fax:
Practice Address - Street 1:6658 NW 4TH AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34475
Practice Address - Country:US
Practice Address - Phone:352-342-1679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA19384225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant