Provider Demographics
NPI:1710645460
Name:TREVIZO, LESLIE (LMT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:TREVIZO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 873
Mailing Address - Street 2:
Mailing Address - City:KERSEY
Mailing Address - State:CO
Mailing Address - Zip Code:80644-0873
Mailing Address - Country:US
Mailing Address - Phone:720-291-2892
Mailing Address - Fax:
Practice Address - Street 1:6200 W 9TH ST UNIT 4B
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-4462
Practice Address - Country:US
Practice Address - Phone:720-291-2892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0016919225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist