Provider Demographics
NPI:1902053671
Name:LEONARD, ASHLEY L
Entity type:Individual
Prefix:MS
First Name:ASHLEY
Middle Name:L
Last Name:LEONARD
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 1:2404 E EMPIRE ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-3630
Mailing Address - Country:US
Mailing Address - Phone:309-663-8275
Mailing Address - Fax:309-662-7872
Practice Address - Street 1:507 E ARMSTRONG AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3201
Practice Address - Country:US
Practice Address - Phone:309-686-1177
Practice Address - Fax:309-686-7722
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-25
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056008428225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370686250001Medicaid
IL144509Medicare PIN