=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851760664
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACY LEITHAUSER LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2015
-----------------------------------------------------
Last Update Date | 11/19/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 418 HARRIS ST #313
-----------------------------------------------------
City | JUNEAU
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99801-1083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-830-0609
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 704 W 11TH ST
-----------------------------------------------------
City | JUNEAU
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99801-1518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-830-0609
-----------------------------------------------------
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 | 101370
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------