Provider Demographics
NPI:1508966060
Name:LEARY, MICHAEL K (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:K
Last Name:LEARY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 CHIPMAN PL
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-2705
Mailing Address - Country:US
Mailing Address - Phone:415-310-8834
Mailing Address - Fax:415-485-0702
Practice Address - Street 1:639 E BLITHEDALE AVE
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-1412
Practice Address - Country:US
Practice Address - Phone:415-310-8834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT107406174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT107460Medicare ID - Type Unspecified