=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639635048
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAITLIN ROSE LESLEY DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2019
-----------------------------------------------------
Last Update Date | 02/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 306 HOSPITAL DR
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39705-1935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-397-5838
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4636 WHITECHAPEL LN
-----------------------------------------------------
City | BELDEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38826-8727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-397-5838
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 6048
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------