Provider Demographics
NPI:1457856965
Name:KO, LESLIE SUSAN (LCMT, BCTMB)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:SUSAN
Last Name:KO
Suffix:
Gender:F
Credentials:LCMT, BCTMB
Other - Prefix:MS
Other - First Name:SUZI
Other - Middle Name:KAWAIONIOKEKAIKAIONA
Other - Last Name:KO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 463
Mailing Address - Street 2:
Mailing Address - City:EL CERRITO
Mailing Address - State:CA
Mailing Address - Zip Code:94530-0463
Mailing Address - Country:US
Mailing Address - Phone:916-416-0491
Mailing Address - Fax:
Practice Address - Street 1:1250 ADDISON ST STE G
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94702-1713
Practice Address - Country:US
Practice Address - Phone:916-416-0491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA327225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist