Provider Demographics
NPI:1669593455
Name:LEATHERS, DENISE REGINA (OT)
Entity type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:REGINA
Last Name:LEATHERS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 STATE RD
Mailing Address - Street 2:
Mailing Address - City:ELIOT
Mailing Address - State:ME
Mailing Address - Zip Code:03903-1087
Mailing Address - Country:US
Mailing Address - Phone:207-451-9120
Mailing Address - Fax:
Practice Address - Street 1:91 MAIN ST
Practice Address - Street 2:
Practice Address - City:PLAISTOW
Practice Address - State:NH
Practice Address - Zip Code:03865-3012
Practice Address - Country:US
Practice Address - Phone:603-382-3031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0A936224Z00000X
MA1442224Z00000X
NH2066225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME0A936OtherCOTA
MA1442OtherCOTA
NH2066OtherNEW HAMPSHIRE