Provider Demographics
NPI:1053751396
Name:LEAVY, LATECIA SHACOLE
Entity type:Individual
Prefix:
First Name:LATECIA
Middle Name:SHACOLE
Last Name:LEAVY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15725 KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:MARKHAM
Mailing Address - State:IL
Mailing Address - Zip Code:60428-3900
Mailing Address - Country:US
Mailing Address - Phone:312-933-4320
Mailing Address - Fax:
Practice Address - Street 1:15725 KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:MARKHAM
Practice Address - State:IL
Practice Address - Zip Code:60428-3900
Practice Address - Country:US
Practice Address - Phone:312-933-4320
Practice Address - Fax:708-232-2916
Is Sole Proprietor?:No
Enumeration Date:2013-07-01
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2170002442355S0801X
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant