Provider Demographics
NPI:1114278207
Name:LEITZKE, TAMARA
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:LEITZKE
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 1:502 4TH ST NE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-5020
Mailing Address - Country:US
Mailing Address - Phone:253-931-4927
Mailing Address - Fax:
Practice Address - Street 1:502 4TH ST NE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-5020
Practice Address - Country:US
Practice Address - Phone:253-931-4927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT 00003683225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics