Provider Demographics
NPI:1114034063
Name:LESLIE, MICHELLE ANN (PTA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:LESLIE
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 1:4226 E FERNWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-5419
Mailing Address - Country:US
Mailing Address - Phone:714-639-0287
Mailing Address - Fax:
Practice Address - Street 1:3100 W WARNER AVE
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-5331
Practice Address - Country:US
Practice Address - Phone:714-595-8946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT3828225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant