Provider Demographics
NPI:1659798601
Name:DIVINAGRACIA, LEAH
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:DIVINAGRACIA
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 1:7903 151ST ST E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98375-8439
Mailing Address - Country:US
Mailing Address - Phone:253-414-5557
Mailing Address - Fax:
Practice Address - Street 1:7903 151ST ST E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98375-8439
Practice Address - Country:US
Practice Address - Phone:253-414-5557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT 60357273225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist