Provider Demographics
NPI:1245562073
Name:LOVELACE, LESLIE COLEMAN (PT)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:COLEMAN
Last Name:LOVELACE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:COLEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:109 BRIDGE ST STE 300
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-1222
Mailing Address - Country:US
Mailing Address - Phone:434-793-4711
Mailing Address - Fax:434-797-2514
Practice Address - Street 1:109 BRIDGE ST STE 300
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-1222
Practice Address - Country:US
Practice Address - Phone:434-793-4711
Practice Address - Fax:434-797-2514
Is Sole Proprietor?:No
Enumeration Date:2010-02-04
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305206355225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2305206355OtherSTATE OF VIRGINIA LICENSE
VA1245562073Medicaid
VA2305206355OtherVA. LICENSE NO.
VAVAA100564Medicare PIN