Provider Demographics
NPI:1558508796
Name:RICHARDSON, LESLIE ANN (LMT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANN
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4970 W HIGHWAY 290
Mailing Address - Street 2:SUITE 480
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-6748
Mailing Address - Country:US
Mailing Address - Phone:512-796-6399
Mailing Address - Fax:
Practice Address - Street 1:7101 WANDERING OAK RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749-1892
Practice Address - Country:US
Practice Address - Phone:512-796-6399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-09
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT028405225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist