Healthcare Provider Details

I. General information

NPI: 1033959440
Provider Name (Legal Business Name): MR. DAVID LEDDY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2024
Last Update Date: 05/31/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5602 176TH ST E STE G102103
PUYALLUP WA
98375-9307
US

IV. Provider business mailing address

38103 112TH AVE E
EATONVILLE WA
98328
US

V. Phone/Fax

Practice location:
  • Phone: 253-847-7646
  • Fax:
Mailing address:
  • Phone: 847-529-8574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number60401854
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: