Provider Demographics
NPI:1861460594
Name:LEAVITT, PHYLLIS E (MA)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:E
Last Name:LEAVITT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 LAS MANANITAS ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1546
Mailing Address - Country:US
Mailing Address - Phone:505-986-0756
Mailing Address - Fax:505-983-4638
Practice Address - Street 1:208 LAS MANANITAS ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-1546
Practice Address - Country:US
Practice Address - Phone:505-986-0756
Practice Address - Fax:505-983-4638
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1301101YP2500X
NM1835106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM54108730Medicaid