=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194357053
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIRSTEN D LEAVELL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2020
-----------------------------------------------------
Last Update Date | 02/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 WILLOW ST
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47448-7013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-988-6666
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 55 WILLOW ST
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47448-7013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-200-8846
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 31007090A.
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------