MEDICARE: LESLIE LOOP PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT-017950-L	PA

General Provider Information

NPI Number	:	1700067519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE LOOP PT

Provider Business Mailing Address
First Line	:	1320 E 33RD ST
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16504-1910
Country	:	US
Telephone Number	:	814-881-1404
Fax Number	:

Provider Business Practice Location Address
First Line	:	2850 E 38TH ST
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16510-2920
Country	:	US
Telephone Number	:	814-899-1023
Fax Number	:	814-898-2456

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/20/2007
Last Update Date	:	11/20/2007

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Directions to “ LESLIE LOOP PT” Practice Location

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