Healthcare Provider Details

I. General information

NPI: 1669216081
Provider Name (Legal Business Name): LESLIE DELACY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2024
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2639 KATHLEEN DR
BRIGHTON MI
48114-4920
US

IV. Provider business mailing address

2639 KATHLEEN DR
BRIGHTON MI
48114-4920
US

V. Phone/Fax

Practice location:
  • Phone: 865-386-1617
  • Fax:
Mailing address:
  • Phone: 865-386-1617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502009067
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: