Provider Demographics
NPI:1629099601
Name:TEDESCO, LESLEY ANNE (DPT, ATC)
Entity Type:Individual
Prefix:MRS
First Name:LESLEY
Middle Name:ANNE
Last Name:TEDESCO
Suffix:
Gender:F
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 EAST 7TH STREET
Mailing Address - Street 2:SUITE 206
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204
Mailing Address - Country:US
Mailing Address - Phone:704-333-1052
Mailing Address - Fax:704-333-1054
Practice Address - Street 1:2630 EAST 7TH STREET
Practice Address - Street 2:SUITE 206
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204
Practice Address - Country:US
Practice Address - Phone:704-333-1052
Practice Address - Fax:704-333-1054
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22105225100000X
NC11356225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY906HOtherBLUE CROSS/BLUE SHIELD
FLU6096AMedicare ID - Type UnspecifiedMEDICARE INDIVIDUAL NUMBE
FLY906HAMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
FLY906HOtherBLUE CROSS/BLUE SHIELD