Provider Demographics
NPI:1164547956
Name:LEACH, WILLIAM G (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:G
Last Name:LEACH
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:MR
Other - First Name:W.
Other - Middle Name:GLYNN
Other - Last Name:LEACH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:8961 YOUREE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-3001
Mailing Address - Country:US
Mailing Address - Phone:318-671-8772
Mailing Address - Fax:318-671-8776
Practice Address - Street 1:8961 YOUREE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-3001
Practice Address - Country:US
Practice Address - Phone:318-671-8772
Practice Address - Fax:318-671-8776
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXCP010730T225100000X
LA02261225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1976792Medicaid
LA3134900Medicaid