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NPI Code Detail

MEDICARE: LEAH A BALONZO P.T.

MEDICARE: LEAH A BALONZO P.T.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical Therapist070.015613IL
2225100000XPhysical Therapist2006032817MO

General Provider Information

NPI Number : 1841442936
Entity Type Code : Individual
Provider Name (Legal Business Name) : LEAH A BALONZO P.T.
Provider Business Mailing Address
First Line : 3354 JEROME LN
Second Line : REHAB DEPT
City : CAHOKIA
State : IL
Zip : 62206-2604
Country : US
Telephone Number : 217-381-7666
Fax Number : 618-332-0456
Provider Business Practice Location Address
First Line : 3354 JEROME LN
Second Line : REHAB DEPT
City : CAHOKIA
State : IL
Zip : 62206-2604
Country : US
Telephone Number : 217-381-7666
Fax Number : 618-332-0456
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/21/2008
Last Update Date : 01/15/2009

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