Provider Demographics
NPI:1598297855
Name:WALTER, LESLIE (LMT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:WALTER
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 1:1403 W PALM DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-4528
Mailing Address - Country:US
Mailing Address - Phone:912-220-1062
Mailing Address - Fax:
Practice Address - Street 1:314 W SUPERIOR ST
Practice Address - Street 2:LL-E, LATERAL FITNESS
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3538
Practice Address - Country:US
Practice Address - Phone:912-220-1062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227010419225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist