Healthcare Provider Details

I. General information

NPI: 1417003526
Provider Name (Legal Business Name): LEIGH RANDOLPH TALLEY PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HIGH POINT CT
MT WASHINGTON KY
40047-6560
US

IV. Provider business mailing address

3131 TALISMAN RD
LOUISVILLE KY
40220-1815
US

V. Phone/Fax

Practice location:
  • Phone: 502-538-2332
  • Fax: 502-538-2514
Mailing address:
  • Phone: 502-492-2200
  • Fax: 502-538-2332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number005053
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: