Provider Demographics
NPI:1871945329
Name:MILLICAN, LEILA
Entity type:Individual
Prefix:
First Name:LEILA
Middle Name:
Last Name:MILLICAN
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 1:4109 HIGHWAY 98 W
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:MS
Mailing Address - Zip Code:39666-9132
Mailing Address - Country:US
Mailing Address - Phone:601-276-3900
Mailing Address - Fax:
Practice Address - Street 1:403 E FLOURNOY LUCAS RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-3906
Practice Address - Country:US
Practice Address - Phone:318-213-3560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-08
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPT04428225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist