Provider Demographics
NPI:1598493140
Name:LEVAULT, LINDSAY A (PTA)
Entity Type:Individual
Prefix:
First Name:LINDSAY
Middle Name:A
Last Name:LEVAULT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1960
Mailing Address - Country:US
Mailing Address - Phone:618-607-0061
Mailing Address - Fax:
Practice Address - Street 1:775 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1960
Practice Address - Country:US
Practice Address - Phone:618-607-0061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.009614208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL14352197709OtherDRIVER'S LICENSE