Provider Demographics
NPI:1457856965
Name:KO, LESLIE SUSAN (LCMT, BCTMB)
Entity type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:SUSAN
Last Name:KO
Suffix:
Gender:
Credentials:LCMT, BCTMB
Other - Prefix:MS
Other - First Name:SUZI
Other - Middle Name:KAWAIONIOKEKAIKAIONA
Other - Last Name:KO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1466 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94702-1221
Mailing Address - Country:US
Mailing Address - Phone:916-416-0491
Mailing Address - Fax:
Practice Address - Street 1:1611 SAN PABLO AVE STE 1
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94702-1367
Practice Address - Country:US
Practice Address - Phone:916-416-0491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2025-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 246Z00000X
CA327225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No172V00000XOther Service ProvidersCommunity Health Worker
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other