Provider Demographics
NPI:1639202930
Name:O'BANNON, LESLEY MICHELLE (OTRL)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:MICHELLE
Last Name:O'BANNON
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:LESLEY
Other - Middle Name:MICHELLE
Other - Last Name:O'BANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ORTL
Mailing Address - Street 1:626 GLENDALE ST
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-4118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:625 OVERLOOK DR
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33884-1626
Practice Address - Country:US
Practice Address - Phone:863-318-1315
Practice Address - Fax:863-326-9432
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 10397225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist