Provider Demographics
NPI:1275700684
Name:LEAKE, ANN D (COTA)
Entity Type:Individual
Prefix:MRS
First Name:ANN
Middle Name:D
Last Name:LEAKE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S4555 HWY CH
Mailing Address - Street 2:
Mailing Address - City:REEDSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53959-9711
Mailing Address - Country:US
Mailing Address - Phone:608-524-7511
Mailing Address - Fax:608-524-7599
Practice Address - Street 1:S4555 HWY CH
Practice Address - Street 2:
Practice Address - City:REEDSBURG
Practice Address - State:WI
Practice Address - Zip Code:53959-9711
Practice Address - Country:US
Practice Address - Phone:608-524-7511
Practice Address - Fax:608-524-7599
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI274027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40671100Medicaid