Provider Demographics
NPI:1487180287
Name:LEASURE, HEATHER (PTA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:LEASURE
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 1:2741 ROOSEVELT DR
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-8943
Mailing Address - Country:US
Mailing Address - Phone:301-707-3636
Mailing Address - Fax:
Practice Address - Street 1:141 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BOONSBORO
Practice Address - State:MD
Practice Address - Zip Code:21713-1203
Practice Address - Country:US
Practice Address - Phone:301-432-5457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA4669225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant