Provider Demographics
NPI:1689344038
Name:PETERSON, LESLIE MARIE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:842 SHERWOOD RD
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15221-3724
Mailing Address - Country:US
Mailing Address - Phone:440-596-0469
Mailing Address - Fax:
Practice Address - Street 1:6785 BUSINESS PKWY
Practice Address - Street 2:
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075-6353
Practice Address - Country:US
Practice Address - Phone:410-579-8999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-16
Last Update Date:2021-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10840225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC10840OtherPHYSICAL THERAPY LICENSE
MD28677OtherPHYSICAL THERAPY LICENSE