Provider Demographics
NPI:1114081569
Name:RUBY, LESLEY (OT)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:
Last Name:RUBY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2178 E 3840 N
Mailing Address - Street 2:
Mailing Address - City:FILER
Mailing Address - State:ID
Mailing Address - Zip Code:83328-5549
Mailing Address - Country:US
Mailing Address - Phone:208-731-1582
Mailing Address - Fax:
Practice Address - Street 1:1007 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUHL
Practice Address - State:ID
Practice Address - Zip Code:83316-1627
Practice Address - Country:US
Practice Address - Phone:208-595-4941
Practice Address - Fax:208-595-4931
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-242225X00000X, 332BC3200X, 225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter