Provider Demographics
NPI:1093376857
Name:MENTELE, LEAH (DPT)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:MENTELE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:WY
Mailing Address - Zip Code:82836-5056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:512 MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:WY
Practice Address - Zip Code:82836-5056
Practice Address - Country:US
Practice Address - Phone:307-655-2509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1884225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist