Provider Demographics
NPI:1578197828
Name:LARIVIERE, LEAH M (PT, DPT)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:M
Last Name:LARIVIERE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:M
Other - Last Name:MOREHOUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:PO BOX 608
Mailing Address - Street 2:
Mailing Address - City:BEAN STATION
Mailing Address - State:TN
Mailing Address - Zip Code:37708-0608
Mailing Address - Country:US
Mailing Address - Phone:423-317-7772
Mailing Address - Fax:423-317-7773
Practice Address - Street 1:325 W MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37813-2237
Practice Address - Country:US
Practice Address - Phone:423-317-7772
Practice Address - Fax:423-317-7773
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12734225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN12734OtherLICENSE NUMBER
TNQ056040Medicaid