Provider Demographics
NPI:1194009118
Name:LEACH, DIANE S (PT)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:S
Last Name:LEACH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1153 BURGOYNE AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FORT EDWARD
Mailing Address - State:NY
Mailing Address - Zip Code:12828-1134
Mailing Address - Country:US
Mailing Address - Phone:518-746-3350
Mailing Address - Fax:
Practice Address - Street 1:1153 BURGOYNE AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:FORT EDWARD
Practice Address - State:NY
Practice Address - Zip Code:12828-1134
Practice Address - Country:US
Practice Address - Phone:518-746-3350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009248-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist