Provider Demographics
NPI:1831165596
Name:LEIS, ALICE BROOKE (PT)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:BROOKE
Last Name:LEIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S BENNETT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-5402
Mailing Address - Country:US
Mailing Address - Phone:910-692-8269
Mailing Address - Fax:910-692-8479
Practice Address - Street 1:210 S BENNETT ST
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-5402
Practice Address - Country:US
Practice Address - Phone:910-692-8269
Practice Address - Fax:910-692-8479
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10424225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2509044Medicare PIN