Provider Demographics
NPI:1477103802
Name:DEJESUS, LESLIE HAIDEZ (LMT)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:HAIDEZ
Last Name:DEJESUS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N VAN DORN ST APT 927
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-1606
Mailing Address - Country:US
Mailing Address - Phone:571-620-2777
Mailing Address - Fax:
Practice Address - Street 1:2841 HARTLAND RD STE 403
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22043-3500
Practice Address - Country:US
Practice Address - Phone:571-620-2777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-17
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019016698225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist