Provider Demographics
NPI:1366830531
Name:LEAKE, DANIEL (LMT)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:LEAKE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 SE 139TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-2306
Mailing Address - Country:US
Mailing Address - Phone:971-998-0966
Mailing Address - Fax:503-667-3403
Practice Address - Street 1:1217 NE BURNSIDE RD STE 701D
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5770
Practice Address - Country:US
Practice Address - Phone:503-348-4797
Practice Address - Fax:503-667-3403
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-22
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20278225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist