Provider Demographics
NPI:1891853065
Name:BURTON, LESLIE TERESA (LMT)
Entity Type:Individual
Prefix:MISS
First Name:LESLIE
Middle Name:TERESA
Last Name:BURTON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:944 S PENINSULA DR
Mailing Address - Street 2:#202
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32118-6403
Mailing Address - Country:US
Mailing Address - Phone:386-679-0972
Mailing Address - Fax:
Practice Address - Street 1:1089 W GRANADA BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8116
Practice Address - Country:US
Practice Address - Phone:386-679-0972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA22517174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist