Provider Demographics
NPI:1497110233
Name:BRAY, LESLEE (MMP, CMT)
Entity Type:Individual
Prefix:
First Name:LESLEE
Middle Name:
Last Name:BRAY
Suffix:
Gender:F
Credentials:MMP, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5305 PINE GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:SHASTA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:96019-2310
Mailing Address - Country:US
Mailing Address - Phone:530-339-1910
Mailing Address - Fax:
Practice Address - Street 1:1647 HARTNELL AVE
Practice Address - Street 2:SUITE 5,
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-2268
Practice Address - Country:US
Practice Address - Phone:530-339-1910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-21
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA894262225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist