Healthcare Provider Details

I. General information

NPI: 1124122601
Provider Name (Legal Business Name): LESLIE ANN WALLOP P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2661 RIVA RD BLDG 600, SUITE 601
ANNAPOLIS MD
21401-7353
US

IV. Provider business mailing address

105 INDIAN SPRING CT
STEVENSVILLE MD
21666-3213
US

V. Phone/Fax

Practice location:
  • Phone: 410-266-6626
  • Fax: 410-266-3026
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number17007
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: