Provider Demographics
NPI:1346922291
Name:TATE, LESLEE B
Entity Type:Individual
Prefix:
First Name:LESLEE
Middle Name:B
Last Name:TATE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11676 RICHMOND ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-6047
Mailing Address - Country:US
Mailing Address - Phone:208-340-0085
Mailing Address - Fax:
Practice Address - Street 1:1906 FAIRVIEW AVE STE 330
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-5425
Practice Address - Country:US
Practice Address - Phone:208-385-3680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOCTAA-2861224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant