Provider Demographics
NPI:1760961353
Name:LEONARD, ALISSA MARIE (MSOT)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:MARIE
Last Name:LEONARD
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:ALISSA
Other - Middle Name:MARIE
Other - Last Name:RETTERATH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSOT
Mailing Address - Street 1:114302 HUNDERTMARK RD
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-1155
Mailing Address - Country:US
Mailing Address - Phone:320-267-4377
Mailing Address - Fax:
Practice Address - Street 1:500 HARVARD ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0363
Practice Address - Country:US
Practice Address - Phone:320-267-4377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5645225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist