Provider Demographics
NPI:1407923204
Name:LESAK, PHYLLIS J (PT)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:J
Last Name:LESAK
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 1:2100 REGIONAL MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:WHARTON
Mailing Address - State:TX
Mailing Address - Zip Code:77488-9719
Mailing Address - Country:US
Mailing Address - Phone:979-532-1700
Mailing Address - Fax:
Practice Address - Street 1:2100 REGIONAL MEDICAL DR
Practice Address - Street 2:
Practice Address - City:WHARTON
Practice Address - State:TX
Practice Address - Zip Code:77488-9719
Practice Address - Country:US
Practice Address - Phone:979-532-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1028967225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX307400702Medicaid
TX874T13OtherBC/BS PROVIDER #
TX874T13OtherBC/BS #
TXPO1206491OtherRAILROAD MEDICARE #
TXP00782885OtherRAILROAD MEDICARE #
TX1028967OtherP.T. LICENSE
TX1028967OtherP.T. LICENSE
TX307400702Medicaid
TX8772B9Medicare PIN