Provider Demographics
NPI:1659618445
Name:GAVIN, LESLIE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:GAVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5316 TRAIL LAKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-1931
Mailing Address - Country:US
Mailing Address - Phone:817-292-8787
Mailing Address - Fax:817-789-6849
Practice Address - Street 1:1000 SAINT LOUIS AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3366
Practice Address - Country:US
Practice Address - Phone:817-921-5020
Practice Address - Fax:817-789-6849
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-14
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX305161225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX207164901Medicaid
TX149984001Medicaid
TX466606Medicare PIN