Provider Demographics
NPI:1295735074
Name:RICKETTS, LESLIE L (MPT)
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:L
Last Name:RICKETTS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12728 STATE LINE RD
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66209
Mailing Address - Country:US
Mailing Address - Phone:816-941-2550
Mailing Address - Fax:816-941-2520
Practice Address - Street 1:13157 STATE LINE RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64145-1650
Practice Address - Country:US
Practice Address - Phone:816-941-2550
Practice Address - Fax:816-941-2520
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-03406225100000X
MO2004024413225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
34387OtherPREFERRED HEALTH PROFESS
MO34387021OtherBLUE CROSS BLUE SHIELD KC
2239593OtherFIRST HEALTH
2229370OtherCCN NETWORK
MO34387021OtherBLUE CROSS BLUE SHIELD KC