Provider Demographics
NPI:1568154862
Name:CRYSTAL LEACH, MD PHYSIATRY AND ASSOCIATES LLC
Entity Type:Organization
Organization Name:CRYSTAL LEACH, MD PHYSIATRY AND ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/MEMBER/OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:IVAHNA
Authorized Official - Last Name:LEACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-915-3461
Mailing Address - Street 1:1296 CRONSON BLVD
Mailing Address - Street 2:UNIT 4444
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-9998
Mailing Address - Country:US
Mailing Address - Phone:504-915-3461
Mailing Address - Fax:
Practice Address - Street 1:17351 MELFORD BLVD
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-4457
Practice Address - Country:US
Practice Address - Phone:240-548-1300
Practice Address - Fax:240-548-1695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-24
Last Update Date:2023-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty