Provider Demographics
NPI:1093995102
Name:MUKOGAWA, LESLIE AILEEN (DPT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:AILEEN
Last Name:MUKOGAWA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25825 S. VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710
Mailing Address - Country:US
Mailing Address - Phone:310-517-2944
Mailing Address - Fax:
Practice Address - Street 1:25825 S. VERMONT AVE
Practice Address - Street 2:
Practice Address - City:HARBOR CITY
Practice Address - State:CA
Practice Address - Zip Code:90710
Practice Address - Country:US
Practice Address - Phone:310-517-2944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT340742251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic