Provider Demographics
NPI:1962019265
Name:LESLEY, CAMERON GAVIN (DPT)
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:GAVIN
Last Name:LESLEY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-0370
Mailing Address - Country:US
Mailing Address - Phone:601-650-9111
Mailing Address - Fax:
Practice Address - Street 1:1058 HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-9121
Practice Address - Country:US
Practice Address - Phone:601-650-9111
Practice Address - Fax:601-650-1972
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT5901225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist