Provider Demographics
NPI:1356821334
Name:FAIRBANKS, LEAH WUETCHER (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:LEAH
Middle Name:WUETCHER
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2075 SHERIDAN DR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14223-1425
Mailing Address - Country:US
Mailing Address - Phone:718-803-8220
Mailing Address - Fax:
Practice Address - Street 1:2075 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14223-1425
Practice Address - Country:US
Practice Address - Phone:718-803-8220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-18
Last Update Date:2018-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043130225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist