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General NPI Number Information
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NPI Number | 1790264356
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Entity Type | Individual
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Provider Name | BRYAN LEAKE PT, DPT
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Gender | Male
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Dates
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Enumeration Date | 08/14/2018
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Last Update Date | 08/14/2018
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Provider Practice Location Address
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Address Line | 572 GARRISONVILLE RD
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City | STAFFORD
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State | VA
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Zip | 22554-3702
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Country | US
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Telephone | 540-659-6408
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 588
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City | GARRISONVILLE
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State | VA
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Zip | 22463-0588
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Country | US
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Telephone | 540-659-6408
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Fax | 540-659-6445
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 2305212204
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License Number State | VA
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