Provider Demographics
NPI:1124401328
Name:LEAHY, TANYA
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:LEAHY
Suffix:
Gender:F
Credentials:
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 52
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:WI
Mailing Address - Zip Code:54822-0052
Mailing Address - Country:US
Mailing Address - Phone:715-764-0212
Mailing Address - Fax:
Practice Address - Street 1:530 RIVER AVE S
Practice Address - Street 2:
Practice Address - City:PRAIRIE FARM
Practice Address - State:WI
Practice Address - Zip Code:54762-9791
Practice Address - Country:US
Practice Address - Phone:715-455-1178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5129-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant