Provider Demographics
NPI:1619376241
Name:LEECH, ADAM (ATC, MED)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:LEECH
Suffix:
Gender:M
Credentials:ATC, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N JOHN R WOODEN DR
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47907-2117
Mailing Address - Country:US
Mailing Address - Phone:765-494-3245
Mailing Address - Fax:
Practice Address - Street 1:900 N JOHN R WOODEN DR
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47907-2117
Practice Address - Country:US
Practice Address - Phone:765-494-3245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001992A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer