Provider Demographics
NPI:1619191350
Name:LEACH, MATTHEW WILLIAM (ATC, PTA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:WILLIAM
Last Name:LEACH
Suffix:
Gender:M
Credentials:ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:STONY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:10980-1328
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:135 ERIE ST E
Practice Address - Street 2:
Practice Address - City:BLAUVELT
Practice Address - State:NY
Practice Address - Zip Code:10913-1823
Practice Address - Country:US
Practice Address - Phone:845-680-2673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006468-1225200000X
NY000228-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer