Provider Demographics
NPI:1689853962
Name:DE REGO, LESSLIE ERICA (LMP)
Entity Type:Individual
Prefix:
First Name:LESSLIE
Middle Name:ERICA
Last Name:DE REGO
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15501 GRANT AVE SW APT 3
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98498-2067
Mailing Address - Country:US
Mailing Address - Phone:360-280-1869
Mailing Address - Fax:
Practice Address - Street 1:15501 GRANT AVE SW APT 3
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98498-2067
Practice Address - Country:US
Practice Address - Phone:360-280-1869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-02
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA22417225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist