Provider Demographics
NPI:1245596428
Name:LEACH, STACEY (DPT, MHA, MSCS)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:LEACH
Suffix:
Gender:F
Credentials:DPT, MHA, MSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4082 FLAG AVE N
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55427-1040
Mailing Address - Country:US
Mailing Address - Phone:319-329-2711
Mailing Address - Fax:763-302-4219
Practice Address - Street 1:4082 FLAG AVE N
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55427-1040
Practice Address - Country:US
Practice Address - Phone:319-329-2711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8943225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist