Provider Demographics
NPI:1225367766
Name:WICHOWSKI, LEIANNA (OTR/L)
Entity Type:Individual
Prefix:
First Name:LEIANNA
Middle Name:
Last Name:WICHOWSKI
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5110 E DALLAS PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-2687
Mailing Address - Country:US
Mailing Address - Phone:618-975-3047
Mailing Address - Fax:
Practice Address - Street 1:5110 E DALLAS PL
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-2687
Practice Address - Country:US
Practice Address - Phone:618-975-3047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-11
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT13899225X00000X
MO2007004044225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891785000Medicaid