Provider Demographics
NPI:1457179400
Name:LEISINGER, MAYA (DPT, PT)
Entity type:Individual
Prefix:
First Name:MAYA
Middle Name:
Last Name:LEISINGER
Suffix:
Gender:F
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5060 CASCADE RD SE STE A
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3808
Mailing Address - Country:US
Mailing Address - Phone:616-754-7040
Mailing Address - Fax:616-754-7888
Practice Address - Street 1:1330 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-2190
Practice Address - Country:US
Practice Address - Phone:616-754-7040
Practice Address - Fax:616-754-7888
Is Sole Proprietor?:No
Enumeration Date:2024-09-30
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501303632225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist