Provider Demographics
NPI:1760640759
Name:DETIENNE, LESLIE A
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:DETIENNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:577 SIENNA AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-2560
Mailing Address - Country:US
Mailing Address - Phone:219-840-0572
Mailing Address - Fax:
Practice Address - Street 1:5934 US HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-4946
Practice Address - Country:US
Practice Address - Phone:219-762-7136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist