Provider Demographics
NPI:1679056238
Name:TREJO, LESLIE (COTA)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:TREJO
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11522 WAYWARD DAISY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-2468
Mailing Address - Country:US
Mailing Address - Phone:210-723-7246
Mailing Address - Fax:
Practice Address - Street 1:11522 WAYWARD DAISY
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78245-2468
Practice Address - Country:US
Practice Address - Phone:210-723-7246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210935224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant