Provider Demographics
NPI:1912552795
Name:LEATHAM, BRIANA CATHERINE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BRIANA
Middle Name:CATHERINE
Last Name:LEATHAM
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:BRIANA
Other - Middle Name:CATHERINE
Other - Last Name:ENGLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1001 E BOGARD RD
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7114
Mailing Address - Country:US
Mailing Address - Phone:907-373-7246
Mailing Address - Fax:907-376-9225
Practice Address - Street 1:1001 E BOGARD RD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7114
Practice Address - Country:US
Practice Address - Phone:907-373-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK146844225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK16969112Medicaid