Provider Demographics
NPI:1942781760
Name:GORLEY, LESLEY
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:
Last Name:GORLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 N JIM WRIGHT FWY # 2
Mailing Address - Street 2:
Mailing Address - City:WHITE SETTLEMENT
Mailing Address - State:TX
Mailing Address - Zip Code:76108-1068
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 N JIM WRIGHT FWY # 2
Practice Address - Street 2:
Practice Address - City:WHITE SETTLEMENT
Practice Address - State:TX
Practice Address - Zip Code:76108-1068
Practice Address - Country:US
Practice Address - Phone:817-900-8441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Z00000X
TX211709224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1942781760Medicaid