Provider Demographics
NPI:1104415181
Name:LEAVITT, ALICIA (LMFTA)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:LEAVITT
Suffix:
Gender:F
Credentials:LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3013 63RD AVE NW
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-8447
Mailing Address - Country:US
Mailing Address - Phone:801-230-9014
Mailing Address - Fax:
Practice Address - Street 1:3560 BRIDGEPORT WAY W STE 2C
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4446
Practice Address - Country:US
Practice Address - Phone:253-460-7248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-13
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMG61115028106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist