Provider Demographics
NPI:1851790406
Name:LEAVITT, KRISTIE (PTA)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:
Last Name:LEAVITT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 MISSIONARY ACRES
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:VT
Mailing Address - Zip Code:05855-5703
Mailing Address - Country:US
Mailing Address - Phone:802-323-2655
Mailing Address - Fax:
Practice Address - Street 1:71 MISSIONARY ACRES
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:VT
Practice Address - Zip Code:05855-5703
Practice Address - Country:US
Practice Address - Phone:802-323-2655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT041.0096035225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant