Provider Demographics
NPI:1316725344
Name:LESIAK, MACY MCKENNA (OTR/L)
Entity type:Individual
Prefix:
First Name:MACY
Middle Name:MCKENNA
Last Name:LESIAK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:MACY
Other - Middle Name:MCKENNA
Other - Last Name:GUSTAFSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:PO BOX 5285
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68802-5285
Mailing Address - Country:US
Mailing Address - Phone:308-675-1853
Mailing Address - Fax:308-210-4121
Practice Address - Street 1:3004 W FAIDLEY AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4109
Practice Address - Country:US
Practice Address - Phone:308-398-5170
Practice Address - Fax:308-398-5175
Is Sole Proprietor?:No
Enumeration Date:2023-09-20
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2843225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist