Provider Demographics
NPI:1104293893
Name:MILLER, LESLIE ANN (PTA)
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:ANN
Last Name:MILLER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S CREEKSIDE TRL
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-5156
Mailing Address - Country:US
Mailing Address - Phone:815-759-8909
Mailing Address - Fax:
Practice Address - Street 1:101 S CREEKSIDE TRL
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-5156
Practice Address - Country:US
Practice Address - Phone:815-759-8909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160007189225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant