Provider Demographics
NPI:1790264356
Name:LEAKE, BRYAN (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
Last Name:LEAKE
Suffix:
Gender:M
Credentials:PT, DPT
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 588
Mailing Address - Street 2:
Mailing Address - City:GARRISONVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22463-0588
Mailing Address - Country:US
Mailing Address - Phone:540-659-6408
Mailing Address - Fax:540-659-6445
Practice Address - Street 1:572 GARRISONVILLE RD
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-3702
Practice Address - Country:US
Practice Address - Phone:540-659-6408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305212204225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist