Provider Demographics
NPI:1780690941
Name:BOONE, LESLIE DIANE (MPT)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:DIANE
Last Name:BOONE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 E. 3RD AVE.
Mailing Address - Street 2:
Mailing Address - City:TRUTH OR CONSEQUENCES
Mailing Address - State:NM
Mailing Address - Zip Code:87901-2602
Mailing Address - Country:US
Mailing Address - Phone:575-894-0485
Mailing Address - Fax:575-894-0495
Practice Address - Street 1:1070 E. 3RD AVE.
Practice Address - Street 2:
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901-2602
Practice Address - Country:US
Practice Address - Phone:575-894-0485
Practice Address - Fax:575-894-0495
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3290225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM02823276Medicaid
NM00Q572OtherBCBS
344629402Medicare PIN