Provider Demographics
NPI:1750659207
Name:DORN, LESLIE LYNN (LMT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:LYNN
Last Name:DORN
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 1:519 55TH STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WESTERN SPIRNGS
Mailing Address - State:IL
Mailing Address - Zip Code:60558-2268
Mailing Address - Country:US
Mailing Address - Phone:708-415-6896
Mailing Address - Fax:
Practice Address - Street 1:915 55TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:WESTERN SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60558-2218
Practice Address - Country:US
Practice Address - Phone:708-415-6896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227006115225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist