Basic Information
| Provider Information | |||||||||
| NPI: | 1942925086 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MADDISON | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1625 W OLYMPIC BLVD STE 600 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900153865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3239992404 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1625 W OLYMPIC BLVD STE 600 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900153865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3239992404 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2022 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.