Provider Demographics
NPI:1417120155
Name:LEVICKY, AUDRA M (PT)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:M
Last Name:LEVICKY
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 1:13 S HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-7546
Mailing Address - Country:US
Mailing Address - Phone:304-624-6554
Mailing Address - Fax:304-624-5223
Practice Address - Street 1:13 S HIGH ST
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501-7546
Practice Address - Country:US
Practice Address - Phone:304-624-6554
Practice Address - Fax:304-624-5223
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-02
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001783225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0158147000Medicaid