Provider Demographics
NPI:1811483597
Name:LEIVO, EMILY BETH
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:BETH
Last Name:LEIVO
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:PO BOX 123
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:MI
Mailing Address - Zip Code:48756-0123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:906 W PAGE ST
Practice Address - Street 2:
Practice Address - City:ROSE CITY
Practice Address - State:MI
Practice Address - Zip Code:48654
Practice Address - Country:US
Practice Address - Phone:989-280-2989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502000035225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant