Healthcare Provider Details

I. General information

NPI: 1366830531
Provider Name (Legal Business Name): DANIEL LEAKE LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2014
Last Update Date: 12/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 NE BURNSIDE RD STE 701D
GRESHAM OR
97030-5770
US

IV. Provider business mailing address

1525 SE 139TH AVE
PORTLAND OR
97233-2306
US

V. Phone/Fax

Practice location:
  • Phone: 503-348-4797
  • Fax: 503-667-3403
Mailing address:
  • Phone: 971-998-0966
  • Fax: 503-667-3403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number20278
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: