Provider Demographics
NPI:1902184427
Name:HUMES, LESLIE (PTA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:HUMES
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 1:4981 TORONTO WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95820-6238
Mailing Address - Country:US
Mailing Address - Phone:218-393-7724
Mailing Address - Fax:
Practice Address - Street 1:9500 MICRON AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95827-2617
Practice Address - Country:US
Practice Address - Phone:916-362-7962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-01
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA1465225200000X
OR08744225200000X
CAAT9674225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant