Provider Demographics
NPI:1891763785
Name:LEACH, SANDY JEAN (PT)
Entity Type:Individual
Prefix:MS
First Name:SANDY
Middle Name:JEAN
Last Name:LEACH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27299 RIVERVIEW CENTER BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-4322
Mailing Address - Country:US
Mailing Address - Phone:239-676-2080
Mailing Address - Fax:
Practice Address - Street 1:6811 PALISADES PARK COURT
Practice Address - Street 2:SUITE 2
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912
Practice Address - Country:US
Practice Address - Phone:239-936-4445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT8331225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY4932ZMedicare ID - Type UnspecifiedTIED TO GROUP NUMBE K1923