Provider Demographics
NPI:1346638103
Name:LEAS, MOLLYE R
Entity Type:Individual
Prefix:
First Name:MOLLYE
Middle Name:R
Last Name:LEAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:MA
Mailing Address - Zip Code:02777-0023
Mailing Address - Country:US
Mailing Address - Phone:508-675-3200
Mailing Address - Fax:508-675-3488
Practice Address - Street 1:5390 PERSHING AVE APT 505
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-1799
Practice Address - Country:US
Practice Address - Phone:812-662-5033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-02
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014039448225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist