Healthcare Provider Details

I. General information

NPI: 1932016334
Provider Name (Legal Business Name): SOPHIA GRACE LEACH
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 FLOYD DR
SIKESTON MO
63801-3960
US

IV. Provider business mailing address

438 RADCLIFF LN
POPLAR BLUFF MO
63901-8532
US

V. Phone/Fax

Practice location:
  • Phone: 573-472-0397
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: