Provider Demographics
NPI:1659954659
Name:LEAVITT, ROBERT TYLER
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:TYLER
Last Name:LEAVITT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 FARM ROAD 1043
Mailing Address - Street 2:
Mailing Address - City:PIERCE CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65723-8501
Mailing Address - Country:US
Mailing Address - Phone:417-393-6047
Mailing Address - Fax:
Practice Address - Street 1:201 S NORTHPARK LN
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-8499
Practice Address - Country:US
Practice Address - Phone:417-623-4313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018035890225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist