Provider Demographics
NPI:1417301383
Name:DAUENBAUGH, LESLI (LMT)
Entity Type:Individual
Prefix:
First Name:LESLI
Middle Name:
Last Name:DAUENBAUGH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 STARLIGHT LN
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41051-7416
Mailing Address - Country:US
Mailing Address - Phone:309-287-5500
Mailing Address - Fax:
Practice Address - Street 1:1922 WALTON NICHOLSON PIKE
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:KY
Practice Address - Zip Code:41051-7901
Practice Address - Country:US
Practice Address - Phone:859-363-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-18
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYBMTMTH00224978225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist