Provider Demographics
NPI:1962197624
Name:LEACH, NICHOLAS (COTA/L)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:
Last Name:LEACH
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:MR
Other - First Name:NICHOLAS
Other - Middle Name:CLARK
Other - Last Name:DENNIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COTA/L
Mailing Address - Street 1:1605 WOODRIDGE DR SE
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-3818
Mailing Address - Country:US
Mailing Address - Phone:360-443-2399
Mailing Address - Fax:
Practice Address - Street 1:1605 WOODRIDGE DR SE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366
Practice Address - Country:US
Practice Address - Phone:360-443-2399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60666287224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant