Provider Demographics
NPI:1568440162
Name:FADDIS, LESLIE D (PT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:D
Last Name:FADDIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:MADISON-HERRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:789 MAIN ST STE 4
Mailing Address - Street 2:GREAT BARRINGTON PHYSICAL THERAPY, INC.
Mailing Address - City:GT BARRINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01230-2217
Mailing Address - Country:US
Mailing Address - Phone:413-528-0929
Mailing Address - Fax:413-528-6123
Practice Address - Street 1:789 MAIN ST STE 4
Practice Address - Street 2:GREAT BARRINGTON PHYSICAL THERAPY, INC.
Practice Address - City:GT BARRINGTON
Practice Address - State:MA
Practice Address - Zip Code:01230-2217
Practice Address - Country:US
Practice Address - Phone:413-528-0929
Practice Address - Fax:413-528-6123
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8549225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY68376Medicare ID - Type Unspecified
MAQX4677Medicare PIN