Provider Demographics
NPI:1760544050
Name:HEIGHBERGER, LESLIE (PT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:HEIGHBERGER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 MALLARD CREEK RUN
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:OH
Mailing Address - Zip Code:44050-9804
Mailing Address - Country:US
Mailing Address - Phone:440-366-1557
Mailing Address - Fax:
Practice Address - Street 1:1317 COOPER FOSTER PARK RD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:OH
Practice Address - Zip Code:44001-1201
Practice Address - Country:US
Practice Address - Phone:440-282-3341
Practice Address - Fax:440-282-9153
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT07393225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2412606Medicaid
OH9290311Medicare ID - Type Unspecified
OH2412606Medicaid