Provider Demographics
NPI:1588171169
Name:LEAF, TROY A (MA60765114)
Entity type:Individual
Prefix:
First Name:TROY
Middle Name:A
Last Name:LEAF
Suffix:
Gender:M
Credentials:MA60765114
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15313 NE 5TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-3378
Mailing Address - Country:US
Mailing Address - Phone:503-496-9844
Mailing Address - Fax:
Practice Address - Street 1:1319 NE 134TH ST STE 103
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-2718
Practice Address - Country:US
Practice Address - Phone:360-574-3141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-05
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60765114225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist