Provider Demographics
NPI:1477664753
Name:LEVENTRY, TIMOTHY LEE LEVENTRY (ORTL)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:LEE LEVENTRY
Last Name:LEVENTRY
Suffix:
Gender:M
Credentials:ORTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1397 EISENHOWER BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904-3267
Mailing Address - Country:US
Mailing Address - Phone:814-262-4236
Mailing Address - Fax:814-262-4237
Practice Address - Street 1:1397 EISENHOWER BLVD
Practice Address - Street 2:SUITE 304
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904-3262
Practice Address - Country:US
Practice Address - Phone:814-262-4236
Practice Address - Fax:814-262-4237
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0C006168L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1022150980001Medicaid
PA106842Medicare PIN
106842Medicare PIN