Provider Demographics
NPI:1962915843
Name:MCGOUGH, LESLIE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:MCGOUGH
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 1:1404 8TH ST N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-4741
Mailing Address - Country:US
Mailing Address - Phone:904-521-2368
Mailing Address - Fax:
Practice Address - Street 1:8491 NW 17TH ST
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33126
Practice Address - Country:US
Practice Address - Phone:305-456-5542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT32990225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist