Provider Demographics
NPI:1891115994
Name:LEACH, CRYSTAL IVAHNA (MD)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:IVAHNA
Last Name:LEACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14640 GOVERNOR SPRIGG PL
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-5910
Mailing Address - Country:US
Mailing Address - Phone:504-915-3461
Mailing Address - Fax:
Practice Address - Street 1:17351 MELFORD BLVD
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-4457
Practice Address - Country:US
Practice Address - Phone:240-548-1300
Practice Address - Fax:240-548-1695
Is Sole Proprietor?:No
Enumeration Date:2014-04-16
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-17056208100000X
GA95216208100000X
DCMD046990208100000X
MDD0085741208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation