Provider Demographics
NPI:1720301351
Name:THROCKMORTON, LESLEY (PT, LMT)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:
Last Name:THROCKMORTON
Suffix:
Gender:F
Credentials:PT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 BUNTON CREEK RD
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-5787
Mailing Address - Country:US
Mailing Address - Phone:512-268-4700
Mailing Address - Fax:512-268-4703
Practice Address - Street 1:135 BUNTON CREEK RD
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-5787
Practice Address - Country:US
Practice Address - Phone:512-268-4700
Practice Address - Fax:512-268-4703
Is Sole Proprietor?:No
Enumeration Date:2010-03-10
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1181247225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX838T42OtherBCBS
TX00636YMedicare PIN
TX317784YLHEMedicare PIN
TX838T42OtherBCBS
TXTXB100817Medicare PIN