Basic Information
| Provider Information | |||||||||
| NPI: | 1255682886 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | LEESA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COTTON | ||||||||
| OtherFirstName: | LEESA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12952 BANDERA RD | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | HELOTES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780234689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106958731 | ||||||||
| FaxNumber: | 2105980432 | ||||||||
| Practice Location | |||||||||
| Address1: | 12952 BANDERA RD | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | HELOTES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780234689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106958731 | ||||||||
| FaxNumber: | 2105980432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2012 | ||||||||
| LastUpdateDate: | 07/14/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1209657 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1209657 | 01 | TX | TEXAS BOARD OF PHYSICAL THERAPY EXAMINEERS | OTHER |