Provider Demographics
NPI:1962981159
Name:GONCALVES THOME, LEONARDO J (PTA)
Entity type:Individual
Prefix:
First Name:LEONARDO
Middle Name:J
Last Name:GONCALVES THOME
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2802 JAMAICA ST
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-2828
Mailing Address - Country:US
Mailing Address - Phone:941-822-1562
Mailing Address - Fax:941-921-0043
Practice Address - Street 1:2830 BEE RIDGE RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239
Practice Address - Country:US
Practice Address - Phone:941-927-1234
Practice Address - Fax:941-921-0043
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28037225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant