Provider Demographics
NPI:1255688222
Name:GEORGE, LESLIE (LMT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:GEORGE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:793 PROMONTORY DR
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48381-1656
Mailing Address - Country:US
Mailing Address - Phone:248-877-5757
Mailing Address - Fax:
Practice Address - Street 1:4123 MARTIN RD
Practice Address - Street 2:SUITE 201
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48390-4151
Practice Address - Country:US
Practice Address - Phone:248-877-5757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI515880-06174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist