Provider Demographics
NPI:1710050745
Name:LEAVITT, MARK A (PT, CFP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:LEAVITT
Suffix:
Gender:M
Credentials:PT, CFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 ELM ST
Mailing Address - Street 2:STE 204
Mailing Address - City:CAMDEN
Mailing Address - State:ME
Mailing Address - Zip Code:04843-1954
Mailing Address - Country:US
Mailing Address - Phone:207-798-1195
Mailing Address - Fax:
Practice Address - Street 1:69 ELM ST STE 204
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:ME
Practice Address - Zip Code:04843-1954
Practice Address - Country:US
Practice Address - Phone:207-798-1195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT1050225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME415407OtherTUFTS
ME127700000Medicaid
ME011457OtherBCBS
ME2111062OtherAETNA
MEM21444OtherCIGNA
ME127700000Medicaid