Provider Demographics
NPI:1104483437
Name:LEAHY, KATHLEEN MARIE (OD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:LEAHY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:M
Other - Last Name:BOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:369 KRATKY DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49696-1181
Mailing Address - Country:US
Mailing Address - Phone:231-590-3690
Mailing Address - Fax:
Practice Address - Street 1:882 M 72 NW
Practice Address - Street 2:
Practice Address - City:KALKASKA
Practice Address - State:MI
Practice Address - Zip Code:49646-8787
Practice Address - Country:US
Practice Address - Phone:231-258-9781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005239152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist