1255682886 NPI number — LEESA J NELSON

Table of content: LEESA J NELSON (NPI 1255682886)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255682886 NPI number — LEESA J NELSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELSON
Provider First Name:
LEESA
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COTTON
Provider Other First Name:
LEESA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1255682886
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/14/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12952 BANDERA RD
Provider Second Line Business Mailing Address:
SUITE 107
Provider Business Mailing Address City Name:
HELOTES
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78023-4689
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-695-8731
Provider Business Mailing Address Fax Number:
210-598-0432

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12952 BANDERA RD
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
HELOTES
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78023-4689
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-695-8731
Provider Business Practice Location Address Fax Number:
210-598-0432
Provider Enumeration Date:
09/22/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1209657 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1209657 . This is a "TEXAS BOARD OF PHYSICAL THERAPY EXAMINEERS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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