Healthcare Provider Details

I. General information

NPI: 1639620628
Provider Name (Legal Business Name): LESLIE M HUMPHREY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LESLIE M BENNETT ATC, LAT

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 10/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 VIA REGATTA ST
WEBSTER TX
77598-4386
US

IV. Provider business mailing address

413 VIA REGATTA ST
WEBSTER TX
77598-4386
US

V. Phone/Fax

Practice location:
  • Phone: 832-577-7809
  • Fax:
Mailing address:
  • Phone: 832-577-7809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT4492
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: