Healthcare Provider Details

I. General information

NPI: 1396411203
Provider Name (Legal Business Name): LESLIE LAUREN TANIS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2021
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 MIDWESTERN PKWY
WICHITA FALLS TX
76302-2211
US

IV. Provider business mailing address

2216 PEER POINT DR SE
CALEDONIA MI
49316-8936
US

V. Phone/Fax

Practice location:
  • Phone: 940-322-0771
  • Fax:
Mailing address:
  • Phone: 616-821-5047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501303048
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: