Provider Demographics
NPI:1669861472
Name:MACDONALD, LESLIE M (DPT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:M
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2811 WALLACE CT
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664-5832
Mailing Address - Country:US
Mailing Address - Phone:334-202-2715
Mailing Address - Fax:
Practice Address - Street 1:1300 BLOOMINGDALE PIKE
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-2685
Practice Address - Country:US
Practice Address - Phone:865-531-2204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-16
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8404225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist