Provider Demographics
NPI:1902571409
Name:LEATHERS, ANDREW SCOTT (OTD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:SCOTT
Last Name:LEATHERS
Suffix:
Gender:M
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10723 N HONEYCREEK LN
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525-8736
Mailing Address - Country:US
Mailing Address - Phone:309-573-3197
Mailing Address - Fax:
Practice Address - Street 1:120 EASTGATE DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571-9236
Practice Address - Country:US
Practice Address - Phone:309-423-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.014226225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist