Provider Demographics
NPI:1851646897
Name:LEATHERWOOD, KATIE MARIE (LP)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:MARIE
Last Name:LEATHERWOOD
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5604 SUMMERHILL RD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-4650
Mailing Address - Country:US
Mailing Address - Phone:903-794-0720
Mailing Address - Fax:903-794-0512
Practice Address - Street 1:5604 SUMMERHILL RD
Practice Address - Street 2:SUITE 7
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-4650
Practice Address - Country:US
Practice Address - Phone:903-794-0720
Practice Address - Fax:903-794-0512
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1554224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist