Provider Demographics
NPI:1619255650
Name:LEAVY, LAKECIA (PT)
Entity Type:Individual
Prefix:
First Name:LAKECIA
Middle Name:
Last Name:LEAVY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12905 S MAY ST
Mailing Address - Street 2:
Mailing Address - City:CALUMET PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60827-6562
Mailing Address - Country:US
Mailing Address - Phone:217-766-3569
Mailing Address - Fax:
Practice Address - Street 1:2304 W 95TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1004
Practice Address - Country:US
Practice Address - Phone:773-233-9570
Practice Address - Fax:773-233-9607
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
NCP17925225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist