Provider Demographics
NPI:1033578844
Name:LEAKE, SHARON (LMT)
Entity Type:Individual
Prefix:MRS
First Name:SHARON
Middle Name:
Last Name:LEAKE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3193 POSSUM CORNER RD
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:MS
Mailing Address - Zip Code:39633-3846
Mailing Address - Country:US
Mailing Address - Phone:601-300-9023
Mailing Address - Fax:
Practice Address - Street 1:19883 OLD SCENIC HWY
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-7367
Practice Address - Country:US
Practice Address - Phone:601-300-9023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-22
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA7987172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist