Provider Demographics
NPI:1376581462
Name:PHILLIPS, LESLEY (OT)
Entity type:Individual
Prefix:
First Name:LESLEY
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 CANAL ST STE 3
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-4589
Mailing Address - Country:US
Mailing Address - Phone:888-855-2674
Mailing Address - Fax:617-250-8243
Practice Address - Street 1:6314 FREDONIA RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23227-1604
Practice Address - Country:US
Practice Address - Phone:804-347-2749
Practice Address - Fax:617-250-8243
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119002694225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOT25083OtherFL LICENSE
VA0119002694OtherVA LICENSE
TX124463OtherTX LICENSURE