Provider Demographics
NPI:1932467925
Name:LESLIE, MICHELLE (LMT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LESLIE
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 1:206 WALNUT ST
Mailing Address - Street 2:PO BOX 383
Mailing Address - City:ROCKPORT
Mailing Address - State:IN
Mailing Address - Zip Code:47635-1357
Mailing Address - Country:US
Mailing Address - Phone:812-686-5237
Mailing Address - Fax:
Practice Address - Street 1:1515 E 18TH STREET
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303
Practice Address - Country:US
Practice Address - Phone:812-686-5237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4368173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist