Basic Information
| Provider Information | |||||||||
| NPI: | 1659618445 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAVIN | ||||||||
| FirstName: | LESLIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5316 TRAIL LAKE DR | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761331931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172928787 | ||||||||
| FaxNumber: | 8177896849 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 SAINT LOUIS AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179215020 | ||||||||
| FaxNumber: | 8177896849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2013 | ||||||||
| LastUpdateDate: | 11/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 305161 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 149984001 | 05 | TX | MEDICAID | 207164901 | 05 | TX | MEDICAID |