Provider Demographics
NPI:1518369917
Name:AVERY, LEAH (DPT)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:AVERY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71901-4003
Mailing Address - Country:US
Mailing Address - Phone:501-622-3334
Mailing Address - Fax:501-622-3331
Practice Address - Street 1:300 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-4003
Practice Address - Country:US
Practice Address - Phone:501-622-3334
Practice Address - Fax:501-622-3331
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT3867225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR102366105Medicaid