Provider Demographics
NPI:1487733473
Name:O'BRYAN, LESLIE MACON (OTR/L, CHT)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:MACON
Last Name:O'BRYAN
Suffix:
Gender:F
Credentials:OTR/L, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 OFFICE PARK DR STE C
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-3597
Mailing Address - Country:US
Mailing Address - Phone:662-281-0022
Mailing Address - Fax:662-281-0067
Practice Address - Street 1:1204 OFFICE PARK DR STE C
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-3597
Practice Address - Country:US
Practice Address - Phone:662-281-0022
Practice Address - Fax:662-281-0067
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS225X00000X
MSOT1383225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN446649Medicare ID - Type Unspecified