Provider Demographics
NPI:1952778201
Name:KERNS-WILSON, LESLEY (LMT)
Entity Type:Individual
Prefix:MRS
First Name:LESLEY
Middle Name:
Last Name:KERNS-WILSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 N PEACE RD STE C
Mailing Address - Street 2:SUITE C
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-8401
Mailing Address - Country:US
Mailing Address - Phone:815-748-7236
Mailing Address - Fax:
Practice Address - Street 1:650 N PEACE RD STE C
Practice Address - Street 2:SUITE C
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-8401
Practice Address - Country:US
Practice Address - Phone:815-748-7236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227011696225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist