Provider Demographics
NPI:1295172013
Name:LEACH, BRANDY ANN (PTA)
Entity type:Individual
Prefix:MRS
First Name:BRANDY
Middle Name:ANN
Last Name:LEACH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:BRANDY
Other - Middle Name:ANN
Other - Last Name:MCLEOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3124 CLYDESDALE DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-3805
Mailing Address - Country:US
Mailing Address - Phone:931-444-0485
Mailing Address - Fax:
Practice Address - Street 1:900 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5244
Practice Address - Country:US
Practice Address - Phone:931-552-3002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5391225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant