Healthcare Provider Details

I. General information

NPI: 1760640759
Provider Name (Legal Business Name): LESLIE A DETIENNE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2008
Last Update Date: 05/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5934 US HIGHWAY 6
PORTAGE IN
46368-4946
US

IV. Provider business mailing address

577 SIENNA AVE
PORTAGE IN
46368-2560
US

V. Phone/Fax

Practice location:
  • Phone: 219-762-7136
  • Fax:
Mailing address:
  • Phone: 219-840-0572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: