Provider Demographics
NPI:1346288990
Name:BLACKWELL, LESLIE COREEN (PT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:COREEN
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1115 BOULDERS PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4067
Mailing Address - Country:US
Mailing Address - Phone:804-560-5595
Mailing Address - Fax:804-560-9029
Practice Address - Street 1:5899 BREMO RD
Practice Address - Street 2:1ST FLOOR
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1935
Practice Address - Country:US
Practice Address - Phone:804-285-2645
Practice Address - Fax:804-287-2786
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305203971225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010092205Medicaid
VA540885859OtherMULTIPLAN
VA540885859OtherCORVEL
VA98999OtherOPTIMA HEALTH
VA192295OtherANTHEM PT
VA540885859OtherFIRST HEALTH/CCN
VA540885859OtherC&O EMPLOYEE'S HEALTHCARE
VA540885859OtherCOMPMANAGEMENT
VA540885859OtherFOCUS
VA540885859OtherPRIVATE HEALTHCARE SYSTEM
VA258462OtherSOUTHERN HEALTH
VA540885859OtherVIRGINIA HEALTH NETWORK
VA540885859OtherPRIVATE HEALTHCARE SYSTEM
VA540885859OtherFIRST HEALTH/CCN