Provider Demographics
NPI:1548435407
Name:DE LEON, MARIVIC OFILAS (RPT)
Entity type:Individual
Prefix:
First Name:MARIVIC
Middle Name:OFILAS
Last Name:DE LEON
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GEDDY DR APT D
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23669-3738
Mailing Address - Country:US
Mailing Address - Phone:765-426-2670
Mailing Address - Fax:
Practice Address - Street 1:1 GEDDY DR APT D
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23669-3738
Practice Address - Country:US
Practice Address - Phone:765-426-2670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-22
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009461A225100000X
MD22117225100000X
VA2305205882225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist