Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 2002023324 | MO |
N | 2251S0007X | Physical Therapist - Sports | 39669 | MO |
N | 2251X0800X | Physical Therapist - Orthopedic | 22067 | MO |
NPI | 1235296112 |
---|---|
Provider Name | Angela Renee Diebal-Lee |
First Address | Alexandria, VA 22303-2270 |
Second Address | Fort Leonard Wood, MO 65473 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/01/2007 |
Last Update Date | 14/02/2019 |