Provider Demographics
NPI:1124304175
Name:LEGGETT, MARLISE HERNANDEZ (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:MARLISE
Middle Name:HERNANDEZ
Last Name:LEGGETT
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:DR
Other - First Name:MARLISE
Other - Middle Name:
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:732 FORD ST
Mailing Address - Street 2:STEPPING STONES
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-1704
Mailing Address - Country:US
Mailing Address - Phone:315-393-3074
Mailing Address - Fax:315-394-7320
Practice Address - Street 1:732 FORD ST
Practice Address - Street 2:STEPPING STONES
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-1704
Practice Address - Country:US
Practice Address - Phone:315-393-3074
Practice Address - Fax:315-394-7320
Is Sole Proprietor?:No
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034324-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY034324-1OtherNYS PHYSICAL THERAPY LICENSE