Provider Demographics
NPI:1417610437
Name:LEAVITT, KELLIE ANN (PTA)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:ANN
Last Name:LEAVITT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:LEAVITT
Other - Middle Name:ANN
Other - Last Name:SPRAGUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4930 W TONTO RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-9222
Mailing Address - Country:US
Mailing Address - Phone:208-241-1804
Mailing Address - Fax:
Practice Address - Street 1:21001 N TATUM BLVD STE 78-1640
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-5244
Practice Address - Country:US
Practice Address - Phone:877-222-5348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-17
Last Update Date:2021-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPTA-014015225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPTA-014015OtherARIZONA STATE BOARD OF PHYSICAL THERAPY