Basic Information
| Provider Information | |||||||||
| NPI: | 1003435462 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALAVSKY | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 328 | ||||||||
| Address2: | |||||||||
| City: | MUSKEGO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531500328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148038680 | ||||||||
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| Practice Location | |||||||||
| Address1: | S74W16775 JANESVILLE RD STE 120 | ||||||||
| Address2: | |||||||||
| City: | MUSKEGO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531507742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144222191 | ||||||||
| FaxNumber: | 4144222193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2020 | ||||||||
| LastUpdateDate: | 04/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 429-19 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.