Provider Demographics
NPI:1700367612
Name:LEIMBACH, CARRISSA D (PTA)
Entity Type:Individual
Prefix:
First Name:CARRISSA
Middle Name:D
Last Name:LEIMBACH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 INDUSTRIAL AVE
Mailing Address - Street 2:
Mailing Address - City:COPPERAS COVE
Mailing Address - State:TX
Mailing Address - Zip Code:76522-1722
Mailing Address - Country:US
Mailing Address - Phone:254-542-0114
Mailing Address - Fax:
Practice Address - Street 1:810 INDUSTRIAL AVE
Practice Address - Street 2:
Practice Address - City:COPPERAS COVE
Practice Address - State:TX
Practice Address - Zip Code:76522-1722
Practice Address - Country:US
Practice Address - Phone:254-542-0114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2128538208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation