Provider Demographics
NPI:1003168915
Name:CARRENO, LEAH MICHELLE (DPT)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:MICHELLE
Last Name:CARRENO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:MICHELLE
Other - Last Name:MARIETTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:2817 REILLY ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:539-682-2522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-03
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0011481225100000X
KS11-04276225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist