Provider Demographics
NPI:1558394700
Name:LEONTIEV, MARINA (DPT)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:LEONTIEV
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12508 CORELLIAN CT
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-7750
Mailing Address - Country:US
Mailing Address - Phone:562-860-9769
Mailing Address - Fax:
Practice Address - Street 1:1165 E SAN ANTONIO DR
Practice Address - Street 2:SUITE A
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-2374
Practice Address - Country:US
Practice Address - Phone:562-428-3556
Practice Address - Fax:562-428-3621
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10359225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT10359AMedicare ID - Type UnspecifiedPPIN