Provider Demographics
NPI:1174775043
Name:MCGREGOR, LESLIE D (PTA)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:D
Last Name:MCGREGOR
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:D
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1340 LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-2619
Mailing Address - Country:US
Mailing Address - Phone:530-753-4609
Mailing Address - Fax:
Practice Address - Street 1:1340 LAKE BLVD
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-2619
Practice Address - Country:US
Practice Address - Phone:530-753-4609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT8841225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant