Provider Demographics
NPI:1801169875
Name:NICHOLSON, LESLEY D
Entity type:Individual
Prefix:
First Name:LESLEY
Middle Name:D
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LESLEY
Other - Middle Name:D
Other - Last Name:TOWERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:9827 WALKER ST
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-3826
Mailing Address - Country:US
Mailing Address - Phone:714-220-9001
Mailing Address - Fax:714-220-9006
Practice Address - Street 1:9827 WALKER ST
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:CA
Practice Address - Zip Code:90630-3826
Practice Address - Country:US
Practice Address - Phone:714-220-9001
Practice Address - Fax:714-220-9006
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-21
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT38761174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT38761OtherPHYSICAL THERAPY
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