=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669864922
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TABITHA LEADBETTER LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2015
-----------------------------------------------------
Last Update Date | 02/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6 MAIN STREET, STE 6
-----------------------------------------------------
City | GRAY
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-576-9364
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1803
-----------------------------------------------------
City | GRAY
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04039-1803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-576-9364
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MT5191
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------