Provider Demographics
NPI:1417644451
Name:LEVENTHAL, LARA NICOLE (OT)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:NICOLE
Last Name:LEVENTHAL
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 1:10680 MEDLOCK BRIDGE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-8420
Mailing Address - Country:US
Mailing Address - Phone:725-209-3053
Mailing Address - Fax:855-927-7788
Practice Address - Street 1:20320 NORTHWEST FWY STE 400A
Practice Address - Street 2:
Practice Address - City:JERSEY VILLAGE
Practice Address - State:TX
Practice Address - Zip Code:77065-5620
Practice Address - Country:US
Practice Address - Phone:725-209-3053
Practice Address - Fax:855-927-7788
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-19
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15279225X00000X
TX124309225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist