Basic Information
| Provider Information | |||||||||
| NPI: | 1184080285 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEITZ | ||||||||
| FirstName: | MONICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | DPT | ||||||||
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| OtherLastName: | BLAESSER | ||||||||
| OtherFirstName: | MONICA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 33900 HARPER AVE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480354258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864169100 | ||||||||
| FaxNumber: | 5864169103 | ||||||||
| Practice Location | |||||||||
| Address1: | 9817 E US HIGHWAY 36 | ||||||||
| Address2: | |||||||||
| City: | AVON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461237954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178607677 | ||||||||
| FaxNumber: | 3178607668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2016 | ||||||||
| LastUpdateDate: | 09/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501017525 | MI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 05012469A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.