Provider Demographics
NPI:1518000827
Name:LEESCH, MARTIN KENNETH (DPT)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:KENNETH
Last Name:LEESCH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2251 COUNTRY CLUB LANE
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:CA
Mailing Address - Zip Code:93662
Mailing Address - Country:US
Mailing Address - Phone:559-896-6565
Mailing Address - Fax:559-896-5740
Practice Address - Street 1:2251 COUNTRY CLUB LANE
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:CA
Practice Address - Zip Code:93662
Practice Address - Country:US
Practice Address - Phone:559-896-6565
Practice Address - Fax:559-896-5740
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6932225200000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant