Provider Demographics
NPI:1689705733
Name:MCKIBBEN, LESLIE KAREN (PT)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:KAREN
Last Name:MCKIBBEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4640 WHIPPLE HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-7661
Mailing Address - Country:US
Mailing Address - Phone:321-259-5592
Mailing Address - Fax:321-259-5592
Practice Address - Street 1:4640 WHIPPLE HOLLOW RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7661
Practice Address - Country:US
Practice Address - Phone:321-259-5592
Practice Address - Fax:321-259-5592
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT5166225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist