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General NPI Number Information
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NPI Number | 1477103802
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Entity Type | Individual
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Provider Name | LESLIE HAIDEZ DEJESUS LMT
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Gender | Female
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Dates
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Enumeration Date | 09/17/2019
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Last Update Date | 09/17/2019
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Provider Practice Location Address
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Address Line | 2841 HARTLAND RD STE 403
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City | FALLS CHURCH
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State | VA
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Zip | 22043-3500
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Country | US
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Telephone | 571-620-2777
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Fax |
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Provider Business Mailing Address
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Address Line | 2500 N VAN DORN ST APT 927
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City | ALEXANDRIA
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State | VA
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Zip | 22302-1606
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Country | US
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Telephone | 571-620-2777
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 0019016698
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License Number State | VA
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