Healthcare Provider Details

I. General information

NPI: 1932467925
Provider Name (Legal Business Name): MICHELLE LESLIE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2012
Last Update Date: 04/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 E 18TH STREET
OWENSBORO KY
42303
US

IV. Provider business mailing address

206 WALNUT ST PO BOX 383
ROCKPORT IN
47635-1357
US

V. Phone/Fax

Practice location:
  • Phone: 812-686-5237
  • Fax:
Mailing address:
  • Phone: 812-686-5237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number4368
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: