Basic Information
| Provider Information | |||||||||
| NPI: | 1841538592 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUECKENHOFF | ||||||||
| FirstName: | LESLIE ANN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PTA ATC | ||||||||
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| OtherLastName: | ESSARY | ||||||||
| OtherFirstName: | LESLIE ANN | ||||||||
| OtherMiddleName: | E | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3301 BERRYWOOD DR | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652016517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734498771 | ||||||||
| FaxNumber: | 5714496563 | ||||||||
| Practice Location | |||||||||
| Address1: | 1002 DIAMOND RDG | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | JEFFERSON CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 651096896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737619360 | ||||||||
| FaxNumber: | 5737619362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2013 | ||||||||
| LastUpdateDate: | 03/18/2015 | ||||||||
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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 | 225200000X | 2012038358 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 2255A2300X | 2010024116 | MO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.