Provider Demographics
NPI:1912493545
Name:LEACH, EBONE (COTA/L)
Entity Type:Individual
Prefix:
First Name:EBONE
Middle Name:
Last Name:LEACH
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9109 LIBERTY RD
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-3521
Mailing Address - Country:US
Mailing Address - Phone:410-655-7373
Mailing Address - Fax:610-612-3052
Practice Address - Street 1:9109 LIBERTY RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-3521
Practice Address - Country:US
Practice Address - Phone:410-655-7373
Practice Address - Fax:601-612-3052
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA02651224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant