Provider Demographics
NPI:1164471892
Name:TERRELL, LESLIE (PT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:TERRELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 S BANDIT RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-9758
Mailing Address - Country:US
Mailing Address - Phone:928-710-1819
Mailing Address - Fax:928-443-9029
Practice Address - Street 1:250 S MCCORMICK ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-4714
Practice Address - Country:US
Practice Address - Phone:928-710-1819
Practice Address - Fax:928-443-9029
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4291225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1887614OtherCHAMP VA
AZ456865-001Medicaid
AZ7393636OtherAETNA
AZ1887614OtherUNITED HEALTHCARE
AZ0310230OtherBCBS
AZ19139712OtherSCF OF ARIZONA
AZ352947100OtherUS DEPARTMENT OF LABOR