Individual
LESLIE GAVIN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1000 SAINT LOUIS AVE, SUITE 102, FORT WORTH, TX 76104-3366
(817) 921-5020
(817) 789-6849
Mailing address
5316 TRAIL LAKE DR, FORT WORTH, TX 76133-1931
(817) 292-8787
(817) 789-6849
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
305161
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
149984001
—
TX
05
—
207164901
—
TX
Enumeration date
01/14/2013
Last updated
11/12/2020
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