Basic Information
| Provider Information | |||||||||
| NPI: | 1346594785 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LISK | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | BROOKE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1613 WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275115928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195358758 | ||||||||
| FaxNumber: | 9195353271 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 BLUE RIDGE RD | ||||||||
| Address2: | SUITE 122 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276128086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197867434 | ||||||||
| FaxNumber: | 9197867437 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2012 | ||||||||
| LastUpdateDate: | 02/09/2015 | ||||||||
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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 | 14011 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.