Provider Demographics
NPI:1730527623
Name:ANDREWS, LESLIE NICOLE (OTA)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:NICOLE
Last Name:ANDREWS
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:NICOLE
Other - Last Name:SPARGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTA
Mailing Address - Street 1:2403 MAIN DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-5223
Mailing Address - Country:US
Mailing Address - Phone:479-966-4883
Mailing Address - Fax:479-445-6130
Practice Address - Street 1:2403 MAIN DR
Practice Address - Street 2:SUITE 5
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-5223
Practice Address - Country:US
Practice Address - Phone:479-966-4883
Practice Address - Fax:479-445-6130
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-13
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A773224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1730527623Medicaid