Provider Demographics
NPI:1841887916
Name:LEATHERMAN, REBECKAH JO
Entity type:Individual
Prefix:
First Name:REBECKAH
Middle Name:JO
Last Name:LEATHERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 BARLOW DR
Mailing Address - Street 2:
Mailing Address - City:SOUDERTON
Mailing Address - State:PA
Mailing Address - Zip Code:18964-2276
Mailing Address - Country:US
Mailing Address - Phone:267-575-6359
Mailing Address - Fax:
Practice Address - Street 1:55 BARLOW DR
Practice Address - Street 2:
Practice Address - City:SOUDERTON
Practice Address - State:PA
Practice Address - Zip Code:18964-2276
Practice Address - Country:US
Practice Address - Phone:267-575-6359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health