Healthcare Provider Details

I. General information

NPI: 1104213784
Provider Name (Legal Business Name): RYAN LEIBREICH MS, ATC,CSCS, USAW-1
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2015
Last Update Date: 04/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 HANOVER MNR APARTMENT F- 108
CARLISLE PA
17013-2035
US

IV. Provider business mailing address

712 HANOVER MNR APARTMENT F- 108
CARLISLE PA
17013-2035
US

V. Phone/Fax

Practice location:
  • Phone: 937-403-8312
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT005116
License Number StatePA

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: