Provider Demographics
NPI:1831119429
Name:SANTIAGO, LESLEY ANNE (PT)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:ANNE
Last Name:SANTIAGO
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 1:27 S ASHBY AVE
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-2803
Mailing Address - Country:US
Mailing Address - Phone:973-994-1320
Mailing Address - Fax:
Practice Address - Street 1:27 S ASHBY AVE
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-2803
Practice Address - Country:US
Practice Address - Phone:973-994-1320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01548100320700000X
NY027323225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities