Provider Demographics
NPI:1013628197
Name:LEI, GENEVA LYN SEVILLENO
Entity Type:Individual
Prefix:
First Name:GENEVA LYN
Middle Name:SEVILLENO
Last Name:LEI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNIT 100104 BOX 2000
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96667-0420
Mailing Address - Country:US
Mailing Address - Phone:671-482-8438
Mailing Address - Fax:
Practice Address - Street 1:133 ROUTE 3
Practice Address - Street 2:
Practice Address - City:DEDEDO
Practice Address - State:GU
Practice Address - Zip Code:96929-6911
Practice Address - Country:US
Practice Address - Phone:671-645-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-08
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUPT-170225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist