Provider Demographics
NPI:1841538592
Name:LUECKENHOFF, LESLIE ANN E (PTA ATC)
Entity type:Individual
Prefix:
First Name:LESLIE ANN
Middle Name:E
Last Name:LUECKENHOFF
Suffix:
Gender:F
Credentials:PTA ATC
Other - Prefix:
Other - First Name:LESLIE ANN
Other - Middle Name:E
Other - Last Name:ESSARY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3301 BERRYWOOD DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6517
Mailing Address - Country:US
Mailing Address - Phone:573-449-8771
Mailing Address - Fax:571-449-6563
Practice Address - Street 1:1002 DIAMOND RDG
Practice Address - Street 2:SUITE 800
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6896
Practice Address - Country:US
Practice Address - Phone:573-761-9360
Practice Address - Fax:573-761-9362
Is Sole Proprietor?:No
Enumeration Date:2013-01-30
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012038358225200000X
MO20100241162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer