Provider Demographics
NPI:1528467784
Name:LEACH, PHILLIP
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:LEACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 ALYSIA CT
Mailing Address - Street 2:APT 207
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-6537
Mailing Address - Country:US
Mailing Address - Phone:803-530-1859
Mailing Address - Fax:
Practice Address - Street 1:490 ALYSIA CT
Practice Address - Street 2:APT 207
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-6537
Practice Address - Country:US
Practice Address - Phone:803-530-1859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-13
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
15022255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer