Provider Demographics
NPI:1184976185
Name:DAUGHERTY, LESLEY ANNE (PTA)
Entity type:Individual
Prefix:
First Name:LESLEY
Middle Name:ANNE
Last Name:DAUGHERTY
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 1:4050 AIRPORT CENTER DRIVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92264
Mailing Address - Country:US
Mailing Address - Phone:760-325-5950
Mailing Address - Fax:
Practice Address - Street 1:4050 AIRPORT CENTER DR
Practice Address - Street 2:SUITE D
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92264-1216
Practice Address - Country:US
Practice Address - Phone:760-325-5950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT8718225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant