Provider Demographics
NPI:1093373359
Name:LEIVA, NICOLETTE MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:MARIE
Last Name:LEIVA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3865 GRANDPINE WAY APT 211
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-4353
Mailing Address - Country:US
Mailing Address - Phone:786-973-3030
Mailing Address - Fax:
Practice Address - Street 1:451 S AMELIA AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-5917
Practice Address - Country:US
Practice Address - Phone:386-734-8614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-02
Last Update Date:2019-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT34369225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist