Provider Demographics
NPI:1609423433
Name:LEITH, BRIAN WILLIAM
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:WILLIAM
Last Name:LEITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2270 DOUGLAS BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3869
Mailing Address - Country:US
Mailing Address - Phone:916-289-8172
Mailing Address - Fax:
Practice Address - Street 1:2270 DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3869
Practice Address - Country:US
Practice Address - Phone:916-289-8172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160939805225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2OtherN/A