Basic Information
| Provider Information | |||||||||
| NPI: | 1720422454 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROCHHAUSEN | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILLIAMS | ||||||||
| OtherFirstName: | LESLIE | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPTA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6767 LAKE WOODLANDS DR | ||||||||
| Address2: | SUITE F | ||||||||
| City: | THE WOODLANDS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773822566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813641122 | ||||||||
| FaxNumber: | 2814193101 | ||||||||
| Practice Location | |||||||||
| Address1: | 6767 LAKE WOODLANDS DR | ||||||||
| Address2: | SUITE F | ||||||||
| City: | THE WOODLANDS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773822566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813641122 | ||||||||
| FaxNumber: | 2814193101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2013 | ||||||||
| LastUpdateDate: | 04/24/2013 | ||||||||
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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 | 225200000X | 2087780 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.