Provider Demographics
NPI:1447929294
Name:LEATHERMAN, MITCHELL SCOTT (DPT)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:SCOTT
Last Name:LEATHERMAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 FOSTER AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-3933
Mailing Address - Country:US
Mailing Address - Phone:804-201-1001
Mailing Address - Fax:
Practice Address - Street 1:9101 FRANKLIN SQUARE DR STE 205
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-3975
Practice Address - Country:US
Practice Address - Phone:443-777-6766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD28660225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist