Provider Demographics
NPI:1760089122
Name:SHOWALTER, LESLIE ANN
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANN
Last Name:SHOWALTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:ANN
Other - Last Name:HALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6720 TAMPA AVE
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-5014
Mailing Address - Country:US
Mailing Address - Phone:818-781-1073
Mailing Address - Fax:
Practice Address - Street 1:6720 TAMPA AVE
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-5014
Practice Address - Country:US
Practice Address - Phone:818-781-1073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5077190275789739OtherCALFRESH
CA909258752OtherBLUE SHIELD OF CALIFORNIA
CA94486299FMedicaid