Provider Demographics
NPI:1639845183
Name:ICARO, LESLIE (MT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:ICARO
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13150 WIDE ACRES RD
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80401-4143
Mailing Address - Country:US
Mailing Address - Phone:303-472-0193
Mailing Address - Fax:
Practice Address - Street 1:4380 HARLAN ST STE 202
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-5137
Practice Address - Country:US
Practice Address - Phone:303-472-0193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0006164225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist