Provider Demographics
NPI:1447464649
Name:SHEATS, LESLIE (MSOT)
Entity type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:
Last Name:SHEATS
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 TWIN PEAKS CIR
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-2170
Mailing Address - Country:US
Mailing Address - Phone:303-678-1428
Mailing Address - Fax:
Practice Address - Street 1:NORTH BROADWAY AND BALSAM
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-9019
Practice Address - Country:US
Practice Address - Phone:303-440-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD996501174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist