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General NPI Number Information
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NPI Number | 1770185514
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Entity Type | Individual
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Provider Name | MIRANDA N LEACH PTA
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Gender | Female
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Dates
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Enumeration Date | 11/16/2020
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Last Update Date | 11/16/2020
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Provider Practice Location Address
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Address Line | 2547 TROJAN DR
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City | GREEN BAY
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State | WI
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Zip | 54304-1436
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Country | US
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Telephone | 573-718-9947
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Fax |
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Provider Business Mailing Address
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Address Line | 2547 TROJAN DR
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City | GREEN BAY
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State | WI
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Zip | 54304-1436
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Country | US
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Telephone | 573-718-9947
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 3105-19
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License Number State | WI
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