Healthcare Provider Details

I. General information

NPI: 1417018474
Provider Name (Legal Business Name): LEAH RACZ P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 02/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10616 METROMONT PKWY SUITE 102
CHARLOTTE NC
28269-7656
US

IV. Provider business mailing address

5516 OLD TOWN LN
GASTONIA NC
28056-8588
US

V. Phone/Fax

Practice location:
  • Phone: 704-597-7228
  • Fax: 704-597-9190
Mailing address:
  • Phone: 704-879-4630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5906-024
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11641
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: