Provider Demographics
NPI:1295486769
Name:IVERSON, LEISEL (ATC)
Entity type:Individual
Prefix:
First Name:LEISEL
Middle Name:
Last Name:IVERSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3025 N SEMINARY AVENUE
Mailing Address - Street 2:GDN
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657
Mailing Address - Country:US
Mailing Address - Phone:219-682-4130
Mailing Address - Fax:
Practice Address - Street 1:1641 N. MILKWAUKEE AVENUE
Practice Address - Street 2:ADLER PARK PLAZA, SUITE 7
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048
Practice Address - Country:US
Practice Address - Phone:847-362-6919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-15
Last Update Date:2022-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0805022412255A2300X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer