Provider Demographics
NPI:1700168796
Name:KHAN-FAROOQI, LESLEY ADDISON (PHD, OTD, OTR)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:ADDISON
Last Name:KHAN-FAROOQI
Suffix:
Gender:F
Credentials:PHD, OTD, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3707 S 2ND ST STE 100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-7049
Mailing Address - Country:US
Mailing Address - Phone:512-324-9170
Mailing Address - Fax:
Practice Address - Street 1:12309 N MOPAC EXPY
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-2577
Practice Address - Country:US
Practice Address - Phone:512-324-9170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116942225X00000X
MA11189225X00000X
LA0TT.200450174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX116942OtherOT LICENSE