Provider Demographics
NPI:1730166398
Name:LEACOCK, KENNETH AIDEN (PT)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:AIDEN
Last Name:LEACOCK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 W 139TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10030-2104
Mailing Address - Country:US
Mailing Address - Phone:212-283-6095
Mailing Address - Fax:212-234-5237
Practice Address - Street 1:233 W 139TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10030-2104
Practice Address - Country:US
Practice Address - Phone:212-283-6095
Practice Address - Fax:212-283-6095
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007365225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY007365OtherP.T. LICENCE
NY007365OtherP.T. LICENCE