Provider Demographics
NPI:1881628386
Name:LEAVELLE, BRENDA KAYE (PT)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:KAYE
Last Name:LEAVELLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:KAYE
Other - Last Name:KEGLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:530 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1913
Mailing Address - Country:US
Mailing Address - Phone:218-786-5360
Mailing Address - Fax:
Practice Address - Street 1:530 E 2ND ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1913
Practice Address - Country:US
Practice Address - Phone:218-786-5360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5262225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40269200Medicaid
6401789OtherMEDICA