Provider Demographics
NPI:1831833656
Name:LEAVITT, KAYLI-SUSAN MAREAN
Entity type:Individual
Prefix:
First Name:KAYLI-SUSAN
Middle Name:MAREAN
Last Name:LEAVITT
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 872
Mailing Address - Street 2:
Mailing Address - City:STANDISH
Mailing Address - State:ME
Mailing Address - Zip Code:04084-0872
Mailing Address - Country:US
Mailing Address - Phone:207-671-0105
Mailing Address - Fax:
Practice Address - Street 1:601 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-2424
Practice Address - Country:US
Practice Address - Phone:207-795-4195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT4264225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEOT4264Medicaid