Basic Information
Provider Information | |||||||||
NPI: | 1013093020 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEONE | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OTR | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 40000 | ||||||||
Address2: |   | ||||||||
City: | VAIL | ||||||||
State: | CO | ||||||||
PostalCode: | 816587520 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9706683169 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 181 SO FRONTAGE ROAD WEST | ||||||||
Address2: |   | ||||||||
City: | VAIL | ||||||||
State: | CO | ||||||||
PostalCode: | 81657 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9706683169 | ||||||||
FaxNumber: | 9706683243 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/31/2006 | ||||||||
LastUpdateDate: | 02/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XH1200X | AA334425 | CO | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 225X00000X | AA334425 | CO | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 1235180308 | 05 | CO |   | MEDICAID | 17408776 | 05 | CO |   | MEDICAID |