Provider Demographics
NPI:1255682886
Name:NELSON, LEESA J
Entity Type:Individual
Prefix:
First Name:LEESA
Middle Name:J
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LEESA
Other - Middle Name:
Other - Last Name:COTTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12952 BANDERA RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-4689
Mailing Address - Country:US
Mailing Address - Phone:210-695-8731
Mailing Address - Fax:210-598-0432
Practice Address - Street 1:12952 BANDERA RD
Practice Address - Street 2:SUITE 107
Practice Address - City:HELOTES
Practice Address - State:TX
Practice Address - Zip Code:78023-4689
Practice Address - Country:US
Practice Address - Phone:210-695-8731
Practice Address - Fax:210-598-0432
Is Sole Proprietor?:No
Enumeration Date:2012-09-22
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1209657225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1209657OtherTEXAS BOARD OF PHYSICAL THERAPY EXAMINEERS