Provider Demographics
NPI:1497354963
Name:LEATHERMAN, MITCHELL (ASPT)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:LEATHERMAN
Suffix:
Gender:M
Credentials:ASPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICHLANDTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18955-1050
Mailing Address - Country:US
Mailing Address - Phone:267-733-7878
Mailing Address - Fax:
Practice Address - Street 1:800 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:HARLEYSVILLE
Practice Address - State:PA
Practice Address - Zip Code:19438-1032
Practice Address - Country:US
Practice Address - Phone:215-256-9501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-25
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI004386208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation