Provider Demographics
NPI:1841442936
Name:BALONZO, LEAH A (PT)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:A
Last Name:BALONZO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3354 JEROME LN
Mailing Address - Street 2:REHAB DEPT
Mailing Address - City:CAHOKIA
Mailing Address - State:IL
Mailing Address - Zip Code:62206-2604
Mailing Address - Country:US
Mailing Address - Phone:217-381-7666
Mailing Address - Fax:618-332-0456
Practice Address - Street 1:3354 JEROME LN
Practice Address - Street 2:REHAB DEPT
Practice Address - City:CAHOKIA
Practice Address - State:IL
Practice Address - Zip Code:62206-2604
Practice Address - Country:US
Practice Address - Phone:217-381-7666
Practice Address - Fax:618-332-0456
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.015613225100000X
MO2006032817225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist