Provider Demographics
NPI:1881149383
Name:HEALING WALLS REHABILITATION LLC
Entity type:Organization
Organization Name:HEALING WALLS REHABILITATION LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LAKECIA
Authorized Official - Middle Name:SHANTEL
Authorized Official - Last Name:LEAVY
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:217-766-3569
Mailing Address - Street 1:12905 S MAY ST
Mailing Address - Street 2:
Mailing Address - City:CALUMET PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60827-6562
Mailing Address - Country:US
Mailing Address - Phone:217-766-3569
Mailing Address - Fax:708-842-2004
Practice Address - Street 1:12905 S MAY ST
Practice Address - Street 2:
Practice Address - City:CALUMET PARK
Practice Address - State:IL
Practice Address - Zip Code:60827-6562
Practice Address - Country:US
Practice Address - Phone:217-766-3569
Practice Address - Fax:708-842-2004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-24
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070018779261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy