Provider Demographics
NPI:1356714760
Name:LEGGON, CARMELLA (OT)
Entity type:Individual
Prefix:
First Name:CARMELLA
Middle Name:
Last Name:LEGGON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1731 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMER
Mailing Address - State:WI
Mailing Address - Zip Code:54724-1512
Mailing Address - Country:US
Mailing Address - Phone:715-568-4671
Mailing Address - Fax:
Practice Address - Street 1:1731 17TH AVE
Practice Address - Street 2:
Practice Address - City:BLOOMER
Practice Address - State:WI
Practice Address - Zip Code:54724-1512
Practice Address - Country:US
Practice Address - Phone:715-568-4671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-06
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4269-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist