Provider Demographics
NPI:1235380858
Name:WILDER, LESLIE ANN (PT)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:ANN
Last Name:WILDER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:ANN
Other - Last Name:ROOTBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:223 BERGEN ST.
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217
Mailing Address - Country:US
Mailing Address - Phone:718-243-0783
Mailing Address - Fax:718-243-0783
Practice Address - Street 1:374 5TH AVE.
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215
Practice Address - Country:US
Practice Address - Phone:718-499-5238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002960-1261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy