Healthcare Provider Details

I. General information

NPI: 1134016108
Provider Name (Legal Business Name): LESLIE ASHLEY WIELAND PT, DPT, ATC, CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2025
Last Update Date: 06/21/2025
Certification Date: 06/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 IRVINE AVE STE 130
NEWPORT BEACH CA
92660-3119
US

IV. Provider business mailing address

7811 TALBERT AVE APT 49
HUNTINGTON BEACH CA
92648-1390
US

V. Phone/Fax

Practice location:
  • Phone: 949-271-0053
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number308014
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000030725
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: