Provider Demographics
NPI:1396850897
Name:WEATHERHEAD, LESLIE A (PT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:WEATHERHEAD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 LE PHILLIP CT., SUITE A
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1917
Mailing Address - Country:US
Mailing Address - Phone:704-707-4282
Mailing Address - Fax:704-795-4389
Practice Address - Street 1:6604 ROBERTA RD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:NC
Practice Address - Zip Code:28075-9532
Practice Address - Country:US
Practice Address - Phone:704-455-1172
Practice Address - Fax:704-440-0166
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT22623225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT22623OtherSTATE LICENSE