Provider Demographics
NPI:1407384001
Name:LEAL, AMY J (PTA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:J
Last Name:LEAL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 PECOS ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-5187
Mailing Address - Country:US
Mailing Address - Phone:575-799-5375
Mailing Address - Fax:
Practice Address - Street 1:1604 W 18TH ST
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-7097
Practice Address - Country:US
Practice Address - Phone:575-359-4719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1403225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant