Provider Demographics
NPI:1235118050
Name:WALLACE, LESLIE MICHELE (PT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:MICHELE
Last Name:WALLACE
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 1:1034 LAWRENCE ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-3440
Mailing Address - Country:US
Mailing Address - Phone:541-284-2084
Mailing Address - Fax:541-485-1087
Practice Address - Street 1:1034 LAWRENCE ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3440
Practice Address - Country:US
Practice Address - Phone:541-284-2084
Practice Address - Fax:541-485-1087
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2726225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist