Provider Demographics
NPI:1144398033
Name:CLODFELTER, LESLIE G (MS, PT)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:G
Last Name:CLODFELTER
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 OAKMONT LN
Mailing Address - Street 2:STE 600C
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:
Practice Address - Street 1:1003 MILL POND LN STE C
Practice Address - Street 2:
Practice Address - City:GREENCASTLE
Practice Address - State:IN
Practice Address - Zip Code:46135-2609
Practice Address - Country:US
Practice Address - Phone:765-653-8494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05003607A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10021150Medicaid
156542Medicare ID - Type Unspecified