Provider Demographics
NPI:1396166708
Name:WALLIS, LESLEA (PT)
Entity type:Individual
Prefix:MRS
First Name:LESLEA
Middle Name:
Last Name:WALLIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3610 SPRINGHILL MEMORIAL DR N
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-1162
Mailing Address - Country:US
Mailing Address - Phone:251-410-3600
Mailing Address - Fax:
Practice Address - Street 1:3610 SPRINGHILL MEMORIAL DR N
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-1162
Practice Address - Country:US
Practice Address - Phone:251-410-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-02
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH5894225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist