Provider Demographics
NPI:1588267363
Name:LEIVA, GLORIA (OTR)
Entity type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:
Last Name:LEIVA
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4021 W BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-4771
Mailing Address - Country:US
Mailing Address - Phone:773-328-5544
Mailing Address - Fax:
Practice Address - Street 1:4021 W BELMONT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-4771
Practice Address - Country:US
Practice Address - Phone:773-328-5544
Practice Address - Fax:773-328-5502
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.002800225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty