Basic Information
| Provider Information | |||||||||
| NPI: | 1922542257 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | GAVIN | ||||||||
| FirstName: | LEAH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41521 W 11 MILE RD | ||||||||
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| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483751803 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3325 N UNIVERSITY DR | ||||||||
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| City: | CORAL SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330654162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543446550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2016 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 247000000X | N | Technologists, Technicians & Other Technical Service Providers | Technician, Health Information | 222Q00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
No ID Information.