Provider Demographics
NPI:1235270240
Name:INNIS, LESLIE SUE (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:SUE
Last Name:INNIS
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3471 CERRILLOS RD
Mailing Address - Street 2:TRAILER # 93
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-7235
Mailing Address - Country:US
Mailing Address - Phone:505-270-6545
Mailing Address - Fax:
Practice Address - Street 1:4515 S MCCLINTOCK DR
Practice Address - Street 2:SUITE#118
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7376
Practice Address - Country:US
Practice Address - Phone:505-270-6545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ5249225100000X
NM164225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist