Provider Demographics
NPI:1114347853
Name:BAKER-MOFFETT, LESLIE JEAN (OTR)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:JEAN
Last Name:BAKER-MOFFETT
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MS
Other - First Name:LESLIEJEAN
Other - Middle Name:
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR
Mailing Address - Street 1:PO BOX 124
Mailing Address - Street 2:
Mailing Address - City:TEHUACANA
Mailing Address - State:TX
Mailing Address - Zip Code:76686-0124
Mailing Address - Country:US
Mailing Address - Phone:254-625-2942
Mailing Address - Fax:
Practice Address - Street 1:1105 E FITZGERALD ST
Practice Address - Street 2:
Practice Address - City:BANGS
Practice Address - State:TX
Practice Address - Zip Code:76823-3232
Practice Address - Country:US
Practice Address - Phone:858-952-1923
Practice Address - Fax:619-374-7101
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100155225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist