Provider Demographics
NPI:1306312020
Name:LEUKUMA, RACHELLE
Entity type:Individual
Prefix:
First Name:RACHELLE
Middle Name:
Last Name:LEUKUMA
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 1:385 W SPRINGCREEK RD
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3335
Mailing Address - Country:US
Mailing Address - Phone:406-890-0169
Mailing Address - Fax:
Practice Address - Street 1:171 HERITAGE WAY
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3145
Practice Address - Country:US
Practice Address - Phone:406-755-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-19
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PTA-LIC-15184225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant