MEDICARE: MRS. DIANE S. LEACH P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	009248-1	NY

General Provider Information

NPI Number	:	1194009118
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DIANE S. LEACH P.T.

Provider Business Mailing Address
First Line	:	1153 BURGOYNE AVE
Second Line	:	SUITE 2
City	:	FORT EDWARD
State	:	NY
Zip	:	12828-1134
Country	:	US
Telephone Number	:	518-746-3350
Fax Number	:

Provider Business Practice Location Address
First Line	:	1153 BURGOYNE AVE
Second Line	:	SUITE 2
City	:	FORT EDWARD
State	:	NY
Zip	:	12828-1134
Country	:	US
Telephone Number	:	518-746-3350
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2011
Last Update Date	:	10/10/2011

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