Provider Demographics
NPI:1346256112
Name:LEATHERMAN, SUSAN MEADOWS (MPT)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MEADOWS
Last Name:LEATHERMAN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 UNDERWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901
Mailing Address - Country:US
Mailing Address - Phone:304-667-1040
Mailing Address - Fax:
Practice Address - Street 1:717 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901
Practice Address - Country:US
Practice Address - Phone:304-645-2525
Practice Address - Fax:304-645-2820
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002237225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810005149Medicaid
WV001814354OtherMT ST BC AND BS
WV001814354OtherMT ST BC AND BS