Provider Demographics
NPI:1255887998
Name:LEACH, NICOLE D (DPT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:D
Last Name:LEACH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 PARK PL STE 2
Mailing Address - Street 2:
Mailing Address - City:SHIPPENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17257-9806
Mailing Address - Country:US
Mailing Address - Phone:717-477-8030
Mailing Address - Fax:717-477-8040
Practice Address - Street 1:915 NE 7TH ST STE 1
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4515
Practice Address - Country:US
Practice Address - Phone:541-728-0974
Practice Address - Fax:541-728-0159
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT025430225100000X
OR63972225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1032649900Medicaid