Provider Demographics
NPI:1720360035
Name:CLARK, LEATHA ANN (DPT)
Entity Type:Individual
Prefix:MRS
First Name:LEATHA
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MISS
Other - First Name:LEATHA
Other - Middle Name:ANN
Other - Last Name:DAMRON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:PO BOX 742
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-0742
Mailing Address - Country:US
Mailing Address - Phone:740-249-4081
Mailing Address - Fax:740-249-4126
Practice Address - Street 1:86 COLUMBUS CIRCLE
Practice Address - Street 2:STE 203
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-1331
Practice Address - Country:US
Practice Address - Phone:740-249-4081
Practice Address - Fax:740-249-4126
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH013398225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist