Provider Demographics
NPI:1952776585
Name:LEIS, ANGELA SULLIVAN (DPT)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:SULLIVAN
Last Name:LEIS
Suffix:
Gender:
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30594
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28230-0594
Mailing Address - Country:US
Mailing Address - Phone:601-987-8202
Mailing Address - Fax:601-718-0293
Practice Address - Street 1:104 BURNEY DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-6621
Practice Address - Country:US
Practice Address - Phone:601-987-8202
Practice Address - Fax:601-718-0293
Is Sole Proprietor?:No
Enumeration Date:2015-12-08
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP20610225100000X
MSPT7874225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS200017063Medicaid