Provider Demographics
NPI:1801994355
Name:LEAVER, RICHARD (PT)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:LEAVER
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 1:607 DEWEY AVE NW
Mailing Address - Street 2:STE 300
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-5283
Mailing Address - Country:US
Mailing Address - Phone:616-356-5000
Mailing Address - Fax:616-356-5001
Practice Address - Street 1:1350 KIRTS BLVD STE 120
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4851
Practice Address - Country:US
Practice Address - Phone:248-519-4900
Practice Address - Fax:248-269-0385
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011119225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI64-00940OtherPHP
MI30658OtherBCBSM
MIMI6211133Medicare PIN
MI64-00940OtherPHP