Provider Demographics
NPI:1033560040
Name:LEATHERWOOD, MONTRICE (CNIM)
Entity Type:Individual
Prefix:
First Name:MONTRICE
Middle Name:
Last Name:LEATHERWOOD
Suffix:
Gender:F
Credentials:CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 IMAD CT
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-3164
Mailing Address - Country:US
Mailing Address - Phone:407-484-0342
Mailing Address - Fax:
Practice Address - Street 1:1880 BEAVER RIDGE CIR
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-3833
Practice Address - Country:US
Practice Address - Phone:404-320-6018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-30
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3062246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic