Provider Demographics
NPI:1790754422
Name:PATAKI, LEAH MAE (MA, ATC, CWT)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:MAE
Last Name:PATAKI
Suffix:
Gender:F
Credentials:MA, ATC, CWT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7080 SUE CT
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-5369
Mailing Address - Country:US
Mailing Address - Phone:815-316-8647
Mailing Address - Fax:
Practice Address - Street 1:3301 N MULFORD RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-5640
Practice Address - Country:US
Practice Address - Phone:815-921-3821
Practice Address - Fax:815-921-3829
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer