Provider Demographics
NPI:1639620628
Name:HUMPHREY, LESLIE M
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:M
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:M
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ATC, LAT
Mailing Address - Street 1:413 VIA REGATTA ST
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-4386
Mailing Address - Country:US
Mailing Address - Phone:832-577-7809
Mailing Address - Fax:
Practice Address - Street 1:413 VIA REGATTA ST
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4386
Practice Address - Country:US
Practice Address - Phone:832-577-7809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT44922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer