Provider Demographics
NPI:1750671145
Name:TERRY, LEAH J (PTA, CMT)
Entity Type:Individual
Prefix:MRS
First Name:LEAH
Middle Name:J
Last Name:TERRY
Suffix:
Gender:F
Credentials:PTA, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10747 US HIGHWAY 50 W
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:IN
Mailing Address - Zip Code:47421-8331
Mailing Address - Country:US
Mailing Address - Phone:812-279-3320
Mailing Address - Fax:
Practice Address - Street 1:3211 E MOORES PIKE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-7129
Practice Address - Country:US
Practice Address - Phone:812-334-7604
Practice Address - Fax:812-334-7705
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-19
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002501A225200000X
INMT20900843225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist