Provider Demographics
NPI:1104019173
Name:LEYKAM, MARISA JEAN (PT)
Entity type:Individual
Prefix:DR
First Name:MARISA
Middle Name:JEAN
Last Name:LEYKAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 ADAMS CIR
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-1820
Mailing Address - Country:US
Mailing Address - Phone:303-939-0591
Mailing Address - Fax:303-939-0883
Practice Address - Street 1:1055 ADAMS CIR
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1820
Practice Address - Country:US
Practice Address - Phone:303-939-0591
Practice Address - Fax:303-939-0883
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7844225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist