Provider Demographics
NPI:1477996338
Name:MULFORD, LESLIE G (LOTR)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:G
Last Name:MULFORD
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 PICKETTS MILL DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-3862
Mailing Address - Country:US
Mailing Address - Phone:318-393-9091
Mailing Address - Fax:
Practice Address - Street 1:612 PICKETTS MILL DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-3862
Practice Address - Country:US
Practice Address - Phone:318-393-9091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ12441225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist