Healthcare Provider Details

I. General information

NPI: 1831271113
Provider Name (Legal Business Name): VICTORIA MARIE LEAKE PT, DPT, OCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VICTORIA MARIE KEITH PT, MPT

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 08/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 E WILLIAM CANNON DR STE 225
AUSTIN TX
78745-6646
US

IV. Provider business mailing address

5114 BALCONES WOODS DR SUITE 306
AUSTIN TX
78759-5273
US

V. Phone/Fax

Practice location:
  • Phone: 512-270-2060
  • Fax: 512-270-2061
Mailing address:
  • Phone: 512-372-3612
  • Fax: 512-372-3943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number1223538
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT017126
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: