Provider Demographics
NPI:1639594518
Name:RANDALL, LESLEY (MS ATR-BC LCAT)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:MS ATR-BC LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 PANORAMA TRL
Mailing Address - Street 2:BUILDING 1 SUITE 230
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625-2404
Mailing Address - Country:US
Mailing Address - Phone:585-415-6547
Mailing Address - Fax:
Practice Address - Street 1:625 PANORAMA TRL
Practice Address - Street 2:BUILDING 1 SUITE 230
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14625-2404
Practice Address - Country:US
Practice Address - Phone:585-415-6547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-28
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001151-1221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist