Healthcare Provider Details

I. General information

NPI: 1346450269
Provider Name (Legal Business Name): LESLEA LATHAM PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CENTRAL AVE SE
ALBUQUERQUE NM
87106-4930
US

IV. Provider business mailing address

524 MISSION AVE NE
ALBUQUERQUE NM
87107-4906
US

V. Phone/Fax

Practice location:
  • Phone: 505-841-1919
  • Fax: 505-222-2954
Mailing address:
  • Phone: 505-345-3624
  • Fax: 505-222-2954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1075
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: