Basic Information
Provider Information | |||||||||
NPI: | 1093888000 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAVIS | ||||||||
FirstName: | LESLIE | ||||||||
MiddleName: | P | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT, DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RASH | ||||||||
OtherFirstName: | LESLIE | ||||||||
OtherMiddleName: | PROCTOR | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DPT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 69030 | ||||||||
Address2: |   | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212649030 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7578732306 | ||||||||
FaxNumber: | 7578732306 | ||||||||
Practice Location | |||||||||
Address1: | 100 WINTERS ST STE 103 | ||||||||
Address2: |   | ||||||||
City: | WEST POINT | ||||||||
State: | VA | ||||||||
PostalCode: | 231819534 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8048439033 | ||||||||
FaxNumber: | 8048439037 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2006 | ||||||||
LastUpdateDate: | 04/16/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305204768 | VA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | P00395278 | 01 | VA | RAILROAD MEDICARE | OTHER | 192965 | 01 | VA | BCBS PHY THERAPY | OTHER | 7922915 | 01 | VA | AETNA | OTHER | 010355613 | 05 | VA |   | MEDICAID |