Provider Demographics
NPI:1205177599
Name:LEATHERMAN, MICHELLE (PTA)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:LEATHERMAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 META CT
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27265-8137
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 AMERICHASE DR
Practice Address - Street 2:SUITE K
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27409-9505
Practice Address - Country:US
Practice Address - Phone:336-665-8445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5017225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant