Provider Demographics
NPI: | 1558566521 |
---|---|
Name: | LEACH, CLIFFORD MATTHEW (DPT) |
Entity Type: | Individual |
Prefix: | |
First Name: | CLIFFORD |
Middle Name: | MATTHEW |
Last Name: | LEACH |
Suffix: | |
Gender: | M |
Credentials: | DPT |
Other - Prefix: | |
Other - First Name: | MATT |
Other - Middle Name: | |
Other - Last Name: | LEACH |
Other - Suffix: | |
Other - Last Name Type: | Other Name |
Other - Credentials: | DPT |
Mailing Address - Street 1: | 6045 ALMA RD |
Mailing Address - Street 2: | STE 320 |
Mailing Address - City: | MCKINNEY |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 75070-2188 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 972-569-9050 |
Mailing Address - Fax: | 972-569-9076 |
Practice Address - Street 1: | 6045 ALMA DR |
Practice Address - Street 2: | STE 320 |
Practice Address - City: | MCKINNEY |
Practice Address - State: | TX |
Practice Address - Zip Code: | 75070 |
Practice Address - Country: | US |
Practice Address - Phone: | 972-569-9050 |
Practice Address - Fax: | 972-569-9076 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-06-19 |
Last Update Date: | 2010-05-25 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | 1172280 | 225100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 207749701 | Medicaid | |
TX | 824T43 | Other | BCBS |
TX | 8T7285 | Other | BCBS |
TX | 207749701 | Medicaid | |
TX | 8F23030 | Medicare PIN |