Provider Demographics
NPI:1912025206
Name:LEEDS, ANDREA (PT, DPT, PCS)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:LEEDS
Suffix:
Gender:F
Credentials:PT, DPT, PCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3335 LT MOSS RD
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7222
Mailing Address - Country:US
Mailing Address - Phone:406-549-6413
Mailing Address - Fax:
Practice Address - Street 1:3335 LT MOSS RD
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7222
Practice Address - Country:US
Practice Address - Phone:406-549-6413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009521174400000X
MTPTP-PT-LIC-22872251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7018120Medicaid
MT100002346Medicaid