Provider Demographics
NPI:1336185198
Name:LEITZA, MICHAEL J (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:LEITZA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24014 W RENWICK RD STE F
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-8708
Mailing Address - Country:US
Mailing Address - Phone:800-974-4378
Mailing Address - Fax:630-515-1536
Practice Address - Street 1:417 E IL ROUTE 173 UNIT 101
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002-9407
Practice Address - Country:US
Practice Address - Phone:800-974-4378
Practice Address - Fax:630-515-1536
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10024-24225100000X
IL070011119225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4045700Medicaid
WI11791524OtherCAQH
WI4045700Medicaid
WIK400281392Medicare PIN
IL0604410001OtherDMERC
ILIL6238018OtherMEDICARE
ILL93554Medicare ID - Type Unspecified
WI859400056OtherMEDICARE
ILL97303Medicare ID - Type Unspecified