Provider Demographics
NPI:1467884577
Name:BURNETT, LEEVI (PTA)
Entity Type:Individual
Prefix:MR
First Name:LEEVI
Middle Name:
Last Name:BURNETT
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 COLLEGE BLVD
Mailing Address - Street 2:
Mailing Address - City:CARMI
Mailing Address - State:IL
Mailing Address - Zip Code:62821-1548
Mailing Address - Country:US
Mailing Address - Phone:618-382-4644
Mailing Address - Fax:618-382-2906
Practice Address - Street 1:216 COLLEGE BLVD.
Practice Address - Street 2:
Practice Address - City:CARMI
Practice Address - State:IL
Practice Address - Zip Code:62821
Practice Address - Country:US
Practice Address - Phone:618-382-4644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160006315225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant