Provider Demographics
NPI:1508273897
Name:OLD, LESLIE (OT)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:
Last Name:OLD
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 THOMPSON BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-4624
Mailing Address - Country:US
Mailing Address - Phone:732-987-5267
Mailing Address - Fax:
Practice Address - Street 1:3349 HWY 138
Practice Address - Street 2:BLDG. B. SUTIE A.
Practice Address - City:WALL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07719-9671
Practice Address - Country:US
Practice Address - Phone:732-280-6050
Practice Address - Fax:732-280-6056
Is Sole Proprietor?:No
Enumeration Date:2014-07-18
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00191500225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist