Provider Demographics
NPI:1720702665
Name:PERRY, LESLIE WAGNER
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:WAGNER
Last Name:PERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1058 KINGS LANDING RD
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443-8385
Mailing Address - Country:US
Mailing Address - Phone:919-522-3344
Mailing Address - Fax:
Practice Address - Street 1:13937 US HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:NC
Practice Address - Zip Code:28443-4041
Practice Address - Country:US
Practice Address - Phone:910-566-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8207225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist