Provider Demographics
NPI:1083767545
Name:RODRIGUEZ-LEAVITT, MAYRA L
Entity Type:Individual
Prefix:MRS
First Name:MAYRA
Middle Name:L
Last Name:RODRIGUEZ-LEAVITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12017 CITRUS LEAF DR
Mailing Address - Street 2:
Mailing Address - City:GIBSONTON
Mailing Address - State:FL
Mailing Address - Zip Code:33534-5661
Mailing Address - Country:US
Mailing Address - Phone:813-677-1507
Mailing Address - Fax:
Practice Address - Street 1:10022 WATER WORKS LN
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-5301
Practice Address - Country:US
Practice Address - Phone:813-663-9828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5577235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist