Healthcare Provider Details

I. General information

NPI: 1558889709
Provider Name (Legal Business Name): LEAH IMIG DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LEAH SUSSMAN

II. Dates (important events)

Enumeration Date: 09/07/2017
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 TRINITY LN STE 111
BLOOMINGTON IL
61704-8112
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2529
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-6461
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number13307
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070039744
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: