Provider Demographics
NPI:1801417035
Name:MANCILL, LESLIE MICHELE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:MICHELE
Last Name:MANCILL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 618
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:TX
Mailing Address - Zip Code:77510-0618
Mailing Address - Country:US
Mailing Address - Phone:409-789-3605
Mailing Address - Fax:
Practice Address - Street 1:104 E HERITAGE DR
Practice Address - Street 2:
Practice Address - City:FRIENDSWOOD
Practice Address - State:TX
Practice Address - Zip Code:77546-3854
Practice Address - Country:US
Practice Address - Phone:281-993-2009
Practice Address - Fax:281-993-2007
Is Sole Proprietor?:No
Enumeration Date:2020-04-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2029429225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant