Provider Demographics
NPI:1003422809
Name:ITCHKAVICH-LEVASSEUR, MAKINA (MS, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:MAKINA
Middle Name:
Last Name:ITCHKAVICH-LEVASSEUR
Suffix:
Gender:F
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 BANCROFT RD
Mailing Address - Street 2:
Mailing Address - City:RINDGE
Mailing Address - State:NH
Mailing Address - Zip Code:03461-5906
Mailing Address - Country:US
Mailing Address - Phone:603-630-1166
Mailing Address - Fax:
Practice Address - Street 1:40 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:RINDGE
Practice Address - State:NH
Practice Address - Zip Code:03461-5045
Practice Address - Country:US
Practice Address - Phone:603-899-1142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH06862255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer