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General NPI Number Information
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NPI Number | 1306064993
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Entity Type | Individual
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Provider Name | PHILLIP LEAVELL PTA
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Gender | Male
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Dates
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Enumeration Date | 04/22/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 4718 23RD AVE
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City | MISSOULA
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State | MT
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Zip | 59803-1163
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Country | US
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Telephone | 406-251-6410
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Fax |
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Provider Business Mailing Address
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Address Line | 100 SAGE LN
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City | HAMILTON
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State | MT
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Zip | 59840-3630
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Country | US
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Telephone | 406-375-2342
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 1966
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License Number State | MT
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Taxonomy #2
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 7347A
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License Number State | AZ
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