Healthcare Provider Details

I. General information

NPI: 1184080285
Provider Name (Legal Business Name): MONICA LEITZ DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MONICA BLAESSER

II. Dates (important events)

Enumeration Date: 01/06/2016
Last Update Date: 01/05/2024
Certification Date: 01/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9817 E US HIGHWAY 36
AVON IN
46123-7954
US

IV. Provider business mailing address

33900 HARPER AVE SUITE 104
CLINTON TOWNSHIP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 317-860-7677
  • Fax: 317-860-7668
Mailing address:
  • Phone: 586-350-2644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501017525
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05012469A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: