Provider Demographics
NPI:1013742782
Name:LEAFBLAD, MARY E (ATC, LAT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:LEAFBLAD
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14606 DALLAS PKWY APT 1100
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-7451
Mailing Address - Country:US
Mailing Address - Phone:715-379-5838
Mailing Address - Fax:
Practice Address - Street 1:14606 DALLAS PKWY APT 1100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-7451
Practice Address - Country:US
Practice Address - Phone:715-379-5838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT54742255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
989154OtherNATIONAL CERTIFICATION NUMBER
TXAT5474OtherSTATE LICENSURE