Provider Demographics
NPI:1770185514
Name:LEACH, MIRANDA N (PTA)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:N
Last Name:LEACH
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 1:2547 TROJAN DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-1436
Mailing Address - Country:US
Mailing Address - Phone:573-718-9947
Mailing Address - Fax:
Practice Address - Street 1:2547 TROJAN DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-1436
Practice Address - Country:US
Practice Address - Phone:573-718-9947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3105-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty