Provider Demographics
NPI:1790741577
Name:LEAVITT, PRISCILLA F (PHD)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:F
Last Name:LEAVITT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:936 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101
Mailing Address - Country:US
Mailing Address - Phone:304-422-7300
Mailing Address - Fax:304-428-3719
Practice Address - Street 1:936 MARKET ST
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101
Practice Address - Country:US
Practice Address - Phone:304-422-7300
Practice Address - Fax:304-428-3719
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV414103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0162899000Medicaid
WVCP03102Medicare PIN
WV0162899000Medicaid