Provider Demographics
NPI:1689727356
Name:DEDMAN, LESLIE BROOKE (MS, PT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:BROOKE
Last Name:DEDMAN
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 REGENCY DR
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-5755
Mailing Address - Country:US
Mailing Address - Phone:501-332-5460
Mailing Address - Fax:
Practice Address - Street 1:1425 POTTS ST
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-5291
Practice Address - Country:US
Practice Address - Phone:501-337-7622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2189225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5U211OtherBLUE CROSS BLUESHIELD