Provider Demographics
NPI:1386778793
Name:PEACH, LEISA REID (LMT)
Entity type:Individual
Prefix:
First Name:LEISA
Middle Name:REID
Last Name:PEACH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 VILLAGE SQUARE BLVD
Mailing Address - Street 2:STE 3 BOX 411
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312-4876
Mailing Address - Country:US
Mailing Address - Phone:850-325-1331
Mailing Address - Fax:
Practice Address - Street 1:1910 BUFORD BLVD STE A
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4668
Practice Address - Country:US
Practice Address - Phone:850-325-1331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA42661225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist