Provider Demographics
NPI:1689646044
Name:KOCH, LESLEY ANNE (PT)
Entity Type:Individual
Prefix:MRS
First Name:LESLEY
Middle Name:ANNE
Last Name:KOCH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:LESLEY
Other - Middle Name:ANN
Other - Last Name:WYKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:7451 WARNER AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-5494
Mailing Address - Country:US
Mailing Address - Phone:714-596-0700
Mailing Address - Fax:714-596-0774
Practice Address - Street 1:7451 WARNER AVE
Practice Address - Street 2:SUITE A
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-5494
Practice Address - Country:US
Practice Address - Phone:714-596-0700
Practice Address - Fax:714-596-0774
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2009-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT227362251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT22736BMedicare ID - Type UnspecifiedPHYSICAL THERAPY