Provider Demographics
NPI:1831626639
Name:LEATHAM, DANIEL (MOT/L)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:LEATHAM
Suffix:
Gender:M
Credentials:MOT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 CALL CREEK DR
Mailing Address - Street 2:STE. 7
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3001
Mailing Address - Country:US
Mailing Address - Phone:208-233-4660
Mailing Address - Fax:208-233-4262
Practice Address - Street 1:1110 CALL CREEK DR
Practice Address - Street 2:STE. 7
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3001
Practice Address - Country:US
Practice Address - Phone:208-233-4660
Practice Address - Fax:208-233-4262
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTL-1761225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist