Provider Demographics
NPI:1821167255
Name:MOORER, LESLIE WISNER (OTRL)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:WISNER
Last Name:MOORER
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:LUISE
Other - Last Name:WISNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:6608 CHADWELL ROAD
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35802-1810
Mailing Address - Country:US
Mailing Address - Phone:256-797-8301
Mailing Address - Fax:
Practice Address - Street 1:2075 MAX LUTHER DRIVE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35810-3859
Practice Address - Country:US
Practice Address - Phone:256-852-5600
Practice Address - Fax:256-852-6722
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2605225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
51532739OtherBLUE CROSS BLUE SHIELD