Provider Demographics
NPI:1255840369
Name:ANDERSON, LEAH MARIE (PTA)
Entity Type:Individual
Prefix:MISS
First Name:LEAH
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 WHITETAIL RUN
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-2292
Mailing Address - Country:US
Mailing Address - Phone:320-237-2947
Mailing Address - Fax:
Practice Address - Street 1:825 1ST AVE NW
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-6846
Practice Address - Country:US
Practice Address - Phone:651-633-7875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-21
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA2194225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant