Provider Demographics
NPI:1245595685
Name:NOVOA, LESLIE BLAKE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:BLAKE
Last Name:NOVOA
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:360-486-6508
Mailing Address - Fax:
Practice Address - Street 1:2555 MARVIN RD NE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-3138
Practice Address - Country:US
Practice Address - Phone:360-412-4200
Practice Address - Fax:360-412-6465
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR69342251X0800X
WAPT602911582251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500647609Medicaid
R173962Medicare PIN
R165851Medicare PIN