Provider Demographics
NPI:1194357053
Name:LEAVELL, KIRSTEN D
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:D
Last Name:LEAVELL
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 1:55 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47448-7013
Mailing Address - Country:US
Mailing Address - Phone:317-200-8846
Mailing Address - Fax:
Practice Address - Street 1:55 WILLOW ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:IN
Practice Address - Zip Code:47448-7013
Practice Address - Country:US
Practice Address - Phone:812-988-6666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-09
Last Update Date:2020-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31007090A.225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist