Provider Demographics
NPI:1730651449
Name:LEISTER, EMILY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:LEISTER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 GROVE AVE APT K
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-4689
Mailing Address - Country:US
Mailing Address - Phone:804-363-0775
Mailing Address - Fax:
Practice Address - Street 1:300B TEMPLE LAKE DR STE 1
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2973
Practice Address - Country:US
Practice Address - Phone:804-524-9036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305212490225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist