Provider Demographics
NPI:1356630289
Name:LESLIE, CAROL ANN (OT)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
Last Name:LESLIE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 EUCLID HEIGHTS BLVD APT 204
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44106-2735
Mailing Address - Country:US
Mailing Address - Phone:216-763-1806
Mailing Address - Fax:
Practice Address - Street 1:24300 CHAGRIN BLVD STE 300A
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5629
Practice Address - Country:US
Practice Address - Phone:216-763-1806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-31
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT001012225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0028740Medicaid
OH9290211Medicare PIN