Provider Demographics
NPI:1689850786
Name:CASTLEBERRY, LEO J (PT)
Entity Type:Individual
Prefix:MR
First Name:LEO
Middle Name:J
Last Name:CASTLEBERRY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 737
Mailing Address - Street 2:
Mailing Address - City:GROVELAND
Mailing Address - State:CA
Mailing Address - Zip Code:95321-0737
Mailing Address - Country:US
Mailing Address - Phone:209-962-4035
Mailing Address - Fax:209-962-5399
Practice Address - Street 1:18687 MAIN STREET
Practice Address - Street 2:
Practice Address - City:GROVELAND
Practice Address - State:CA
Practice Address - Zip Code:95321
Practice Address - Country:US
Practice Address - Phone:209-962-4035
Practice Address - Fax:209-962-5399
Is Sole Proprietor?:No
Enumeration Date:2008-01-18
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT12522225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist