Provider Demographics
NPI:1639673619
Name:LEYSON, JOACHIMA ANN KING
Entity Type:Individual
Prefix:
First Name:JOACHIMA ANN
Middle Name:KING
Last Name:LEYSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15030 TAYLOR BLVD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-3992
Mailing Address - Country:US
Mailing Address - Phone:313-445-3718
Mailing Address - Fax:
Practice Address - Street 1:28910 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-2337
Practice Address - Country:US
Practice Address - Phone:723-425-4814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012803225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty