Provider Demographics
NPI:1568904522
Name:CARROLL, LESLIE TATUM (ATC)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:TATUM
Last Name:CARROLL
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 VICTORY AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-6020
Mailing Address - Country:US
Mailing Address - Phone:408-390-4494
Mailing Address - Fax:
Practice Address - Street 1:1809 VICTORY AVE
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-6020
Practice Address - Country:US
Practice Address - Phone:408-390-4494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT48492255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer