Healthcare Provider Details

I. General information

NPI: 1285759431
Provider Name (Legal Business Name): VINCENT JOSEPH LEAVEY MS, ATC, PES, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 05/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 MEMORIAL AVE
WESTMONT NJ
08108-3398
US

IV. Provider business mailing address

11 E 3RD AVE
PINE HILL NJ
08021-6203
US

V. Phone/Fax

Practice location:
  • Phone: 856-869-7750
  • Fax:
Mailing address:
  • Phone: 856-504-6819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00132700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: