Provider Demographics
NPI:1407290059
Name:LEESON, VIRGINIA (MSOTR/L, CLT)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:LEESON
Suffix:
Gender:F
Credentials:MSOTR/L, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:479 NW PRIMA VISTA BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-8731
Mailing Address - Country:US
Mailing Address - Phone:772-408-4848
Mailing Address - Fax:772-408-0978
Practice Address - Street 1:479 NW PRIMA VISTA BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-8731
Practice Address - Country:US
Practice Address - Phone:772-408-4848
Practice Address - Fax:772-408-0978
Is Sole Proprietor?:No
Enumeration Date:2013-04-25
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV090187225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist