Provider Demographics
NPI:1306054051
Name:LEAVITT, CAROLYN RENEE
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:RENEE
Last Name:LEAVITT
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 1:12745 SW 69TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-6220
Mailing Address - Country:US
Mailing Address - Phone:305-662-1610
Mailing Address - Fax:
Practice Address - Street 1:6705 RED ROAD SUITE 611
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33143
Practice Address - Country:US
Practice Address - Phone:305-662-1610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0064799174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist