Provider Demographics
NPI:1750444956
Name:WALLACE, LESLIE ANN (OT)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43922 CANAL RD
Mailing Address - Street 2:
Mailing Address - City:RONAN
Mailing Address - State:MT
Mailing Address - Zip Code:59864-9192
Mailing Address - Country:US
Mailing Address - Phone:406-676-2912
Mailing Address - Fax:406-676-2912
Practice Address - Street 1:43922 CANAL RD
Practice Address - Street 2:
Practice Address - City:RONAN
Practice Address - State:MT
Practice Address - Zip Code:59864-9192
Practice Address - Country:US
Practice Address - Phone:406-676-2912
Practice Address - Fax:406-676-2912
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT186225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Not Answered225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0341343Medicaid
MT66351OtherBCBS PROVIDER NUMBER