Provider Demographics
NPI:1093992299
Name:PARKER, LESLIE NICOLE (MS OTRIL)
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:NICOLE
Last Name:PARKER
Suffix:
Gender:F
Credentials:MS OTRIL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 BRIARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25704-8807
Mailing Address - Country:US
Mailing Address - Phone:304-453-4479
Mailing Address - Fax:
Practice Address - Street 1:212 NORTH COURT STREET
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:WV
Practice Address - Zip Code:25570
Practice Address - Country:US
Practice Address - Phone:304-272-5116
Practice Address - Fax:304-272-5993
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1018225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7503093000Medicaid