Provider Demographics
NPI:1326433855
Name:LEATHERS, MISTI S (MS,OTR/L)
Entity Type:Individual
Prefix:
First Name:MISTI
Middle Name:S
Last Name:LEATHERS
Suffix:
Gender:F
Credentials:MS,OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 GILMAN PLAZA
Mailing Address - Street 2:C/O WATCH ME SHINE, INC.
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401
Mailing Address - Country:US
Mailing Address - Phone:207-990-0162
Mailing Address - Fax:207-990-0163
Practice Address - Street 1:28 GILMAN PLAZA
Practice Address - Street 2:C/O WATCH ME SHINE, INC.
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401
Practice Address - Country:US
Practice Address - Phone:207-990-0162
Practice Address - Fax:207-990-0163
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT2967225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics