Individual
MRS. LESLIE D EDGECOMB
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
O.T.
Contact information
Practice address
5949 W RAYMOND ST, INDIANAPOLIS, IN 46241-4348
(317) 390-5575
(317) 486-2189
Mailing address
790 REMINGTON BLVD, BOLINGBROOK, IL 60440-4909
(630) 296-2223
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
31001170A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000213935
ANTHEM ID
IN
05
—
200117530
—
IN
01
—
P01023463
MEDICARE RR
IN
Enumeration date
04/03/2006
Last updated
05/24/2012
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