Provider Demographics
NPI:1700951696
Name:BALLARD, LESLIE (LMP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:BALLARD
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15625 42ND AVE S
Mailing Address - Street 2:E24
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98188-2658
Mailing Address - Country:US
Mailing Address - Phone:206-579-1668
Mailing Address - Fax:206-246-4686
Practice Address - Street 1:15625 42ND AVE S
Practice Address - Street 2:E24
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-2658
Practice Address - Country:US
Practice Address - Phone:206-579-1668
Practice Address - Fax:206-246-4686
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023303225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist