Provider Demographics
NPI:1043372741
Name:LANDEN, LESLIE COLE (P T)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:COLE
Last Name:LANDEN
Suffix:
Gender:F
Credentials:P T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4556 CANDYTUFT WAY NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-8155
Mailing Address - Country:US
Mailing Address - Phone:770-592-3941
Mailing Address - Fax:
Practice Address - Street 1:2015 VAUGHN RD NW STE 130
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-7851
Practice Address - Country:US
Practice Address - Phone:770-425-6661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3330225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist