Provider Demographics
NPI:1508874744
Name:BOENTE, LEAH (PT, DPT, CERT MDT)
Entity Type:Individual
Prefix:MRS
First Name:LEAH
Middle Name:
Last Name:BOENTE
Suffix:
Gender:F
Credentials:PT, DPT, CERT MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 W WHITE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-6498
Mailing Address - Country:US
Mailing Address - Phone:217-546-3301
Mailing Address - Fax:217-546-3302
Practice Address - Street 1:2201 W WHITE OAKS DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-6498
Practice Address - Country:US
Practice Address - Phone:217-546-3301
Practice Address - Fax:217-546-3302
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL70009000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08432067OtherBLUE CROSS BLUE SHIELD
ILK37379Medicare UPIN