Provider Demographics
NPI:1689893976
Name:LEAVY, AMANDA LYNN (PT)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:LYNN
Last Name:LEAVY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:DR
Other - First Name:AMANDA
Other - Middle Name:LYNN
Other - Last Name:GULKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT, CSCS
Mailing Address - Street 1:2401 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-780-1891
Mailing Address - Fax:
Practice Address - Street 1:4401 S 11TH ST; STE 1000-CENTER FOR PREVENTION & GENETI
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201
Practice Address - Country:US
Practice Address - Phone:701-780-7620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1429225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist