Provider Demographics
NPI:1376280347
Name:LEISSNER, BRADY LATHAM
Entity Type:Individual
Prefix:
First Name:BRADY
Middle Name:LATHAM
Last Name:LEISSNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2051 MAYFIELD PKWY APT 1221
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76033-4226
Mailing Address - Country:US
Mailing Address - Phone:325-493-8990
Mailing Address - Fax:
Practice Address - Street 1:1014 N NOLAN RIVER RD UNIT B
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-7936
Practice Address - Country:US
Practice Address - Phone:817-406-1408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-19
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1360214261QP2000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy