Basic Information
| Provider Information | |||||||||
| NPI: | 1013403690 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAFFETY | ||||||||
| FirstName: | LEAH | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 724557 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 311391557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004782778 | ||||||||
| FaxNumber: | 9099858834 | ||||||||
| Practice Location | |||||||||
| Address1: | 5401 CORPORATE WOODS DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325048974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509126840 | ||||||||
| FaxNumber: | 8509126843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2018 | ||||||||
| LastUpdateDate: | 07/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT33703 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT33703 | 01 | FL | FLORIDA HEALTH DEPARTMENT | OTHER |