Provider Demographics
NPI:1811342777
Name:BURRELL, LESLIE BRIDGET (OTR/L)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:BRIDGET
Last Name:BURRELL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 N COAST HWY APT B
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-1675
Mailing Address - Country:US
Mailing Address - Phone:801-518-2711
Mailing Address - Fax:
Practice Address - Street 1:970 CALLE AMANECER
Practice Address - Street 2:SUITE A
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6250
Practice Address - Country:US
Practice Address - Phone:949-498-5100
Practice Address - Fax:949-366-5665
Is Sole Proprietor?:No
Enumeration Date:2016-04-28
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15436225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist