Provider Demographics
NPI:1043658719
Name:PRENDERGAST, LESLIE (PT)
Entity type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:
Last Name:PRENDERGAST
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 MANGER RD
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-1708
Mailing Address - Country:US
Mailing Address - Phone:973-736-7121
Mailing Address - Fax:
Practice Address - Street 1:44 MANGER RD
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1708
Practice Address - Country:US
Practice Address - Phone:973-736-7121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-04
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01293900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist