Provider Demographics
NPI:1942769278
Name:GERONIMO, LEONCIO KING MENGUITO (MOT, OTR/L)
Entity Type:Individual
Prefix:MR
First Name:LEONCIO KING
Middle Name:MENGUITO
Last Name:GERONIMO
Suffix:
Gender:M
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2171 W EXECUTIVE DR STE 500
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-5626
Mailing Address - Country:US
Mailing Address - Phone:630-766-0505
Mailing Address - Fax:
Practice Address - Street 1:2021 RANDI DR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-4758
Practice Address - Country:US
Practice Address - Phone:630-692-0450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-16
Last Update Date:2019-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL012691225X00000X
IL056.12691225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist