Provider Demographics
NPI:1538226196
Name:INNISS, LEAH ASHTON (RPT)
Entity type:Individual
Prefix:MRS
First Name:LEAH
Middle Name:ASHTON
Last Name:INNISS
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
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Mailing Address - Street 1:6475 ALVARADO RD
Mailing Address - Street 2:STE 118
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5007
Mailing Address - Country:US
Mailing Address - Phone:619-670-3697
Mailing Address - Fax:
Practice Address - Street 1:6475 ALVARADO RD
Practice Address - Street 2:#118
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5003
Practice Address - Country:US
Practice Address - Phone:619-287-4678
Practice Address - Fax:619-287-0350
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 103342251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14455Medicare ID - Type UnspecifiedPT OUTPATIENT CLINIC