Active NPI
Derrick Andre Leach
- Massage Therapist
- Ellenwood, GA
National Provider Identifier
1568079911
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Massage Therapist
- License
- MT008448
- Practice address
- 5685 Washakie PT
Ellenwood, GA 30294-6697 - Phone
- (404) 396-3850
- NPI assigned
- Sep 29, 2020
- Last updated
- Sep 29, 2020
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Massage Therapist | 225700000X | MT008448 | GA | Primary |
Addresses
Primary practice location
5685 Washakie PT
Ellenwood, GA 30294-6697
Mailing address
5685 Washakie PT
Ellenwood, GA 30294-6697
Phone (404) 396-3850
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| MT008448 | GA | MD | Massage Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1601337600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1601337600000",
"number": "1568079911",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "5685 WASHAKIE PT",
"city": "ELLENWOOD",
"state": "GA",
"postal_code": "302946697",
"telephone_number": "404-396-3850"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "5685 WASHAKIE PT",
"city": "ELLENWOOD",
"state": "GA",
"postal_code": "302946697",
"telephone_number": "404-396-3850"
}
],
"practiceLocations": [],
"basic": {
"last_name": "LEACH",
"first_name": "DERRICK",
"middle_name": "ANDRE",
"name_prefix": "Mr.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2020-09-29",
"last_updated": "2020-09-29",
"certification_date": "2020-09-29",
"status": "A"
},
"taxonomies": [
{
"code": "225700000X",
"taxonomy_group": "",
"desc": "Massage Therapist",
"state": "GA",
"license": "MT008448",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Ellenwood, GA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 29, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.