Provider Demographics
NPI:1255505780
Name:MONCLOA, LEONOR (PT)
Entity Type:Individual
Prefix:
First Name:LEONOR
Middle Name:
Last Name:MONCLOA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 N LITCHFIELD RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-7804
Mailing Address - Country:US
Mailing Address - Phone:623-935-5505
Mailing Address - Fax:623-935-5551
Practice Address - Street 1:18275 N 59TH AVE
Practice Address - Street 2:BLDG N STE 186
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1260
Practice Address - Country:US
Practice Address - Phone:602-588-0320
Practice Address - Fax:602-588-0325
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2015-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ80552251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ138790Medicare PIN
AZ333092Medicaid