Provider Demographics
NPI:1689005811
Name:HODGE, LESLIE RENEE (ATC)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:RENEE
Last Name:HODGE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1438 SEYMOUR DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-3916
Mailing Address - Country:US
Mailing Address - Phone:434-517-9947
Mailing Address - Fax:434-517-9949
Practice Address - Street 1:1438 SEYMOUR DR
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-3916
Practice Address - Country:US
Practice Address - Phone:434-517-9947
Practice Address - Fax:434-517-9949
Is Sole Proprietor?:No
Enumeration Date:2013-12-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260017202255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer