Provider Demographics
NPI:1518406677
Name:HAMILTON, LESLIE MARK (LMT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:MARK
Last Name:HAMILTON
Suffix:
Gender:M
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:PO BOX 118
Mailing Address - Street 2:
Mailing Address - City:FORT GEORGE G MEADE
Mailing Address - State:MD
Mailing Address - Zip Code:20755-0118
Mailing Address - Country:US
Mailing Address - Phone:443-432-5529
Mailing Address - Fax:
Practice Address - Street 1:7949 TOWER COURT RD
Practice Address - Street 2:
Practice Address - City:SEVERN
Practice Address - State:MD
Practice Address - Zip Code:21144-1503
Practice Address - Country:US
Practice Address - Phone:443-432-5529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM05747225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist