Provider Demographics
NPI:1033157953
Name:LEACH, KATHI (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHI
Middle Name:
Last Name:LEACH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 239
Mailing Address - Street 2:
Mailing Address - City:MOSINEE
Mailing Address - State:WI
Mailing Address - Zip Code:54455-0239
Mailing Address - Country:US
Mailing Address - Phone:715-693-2400
Mailing Address - Fax:715-693-4699
Practice Address - Street 1:412 3RD ST
Practice Address - Street 2:
Practice Address - City:MOSINEE
Practice Address - State:WI
Practice Address - Zip Code:54455-1425
Practice Address - Country:US
Practice Address - Phone:715-693-2400
Practice Address - Fax:715-693-4699
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1677-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38516100Medicaid
WI0299800001Medicare NSC
WI47220-0000Medicare PIN
WI38516100Medicaid