Provider Demographics
NPI:1194597633
Name:PHAGAN, LESLIE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:PHAGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:662 GORDON RD
Mailing Address - Street 2:
Mailing Address - City:ROCHELLE
Mailing Address - State:GA
Mailing Address - Zip Code:31079-5547
Mailing Address - Country:US
Mailing Address - Phone:229-938-5031
Mailing Address - Fax:
Practice Address - Street 1:815 LEGION DR
Practice Address - Street 2:
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023-6782
Practice Address - Country:US
Practice Address - Phone:478-374-5571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-27
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002642225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant