Provider Demographics
NPI:1639306996
Name:LESH, FREDA MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:FREDA
Middle Name:MARIE
Last Name:LESH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:FREDA
Other - Middle Name:MARIE
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:525 S MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2802
Mailing Address - Country:US
Mailing Address - Phone:708-860-0897
Mailing Address - Fax:
Practice Address - Street 1:525 S MADISON AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2802
Practice Address - Country:US
Practice Address - Phone:708-860-0897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017149225100000X
IL070.017149225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216859021Medicare PIN
IL212622001Medicare PIN
IL212623002Medicare PIN
IL209796003Medicare PIN
IL213392003Medicare PIN
IL214708003Medicare PIN
IL202845035Medicare PIN