Basic Information
| Provider Information | |||||||||
| NPI: | 1205030400 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEGUIRE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636643 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409604000 | ||||||||
| FaxNumber: | 4409604017 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 KOLBE RD | ||||||||
| Address2: | BEHAVIORAL HEALTH UNIT | ||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440531611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409604000 | ||||||||
| FaxNumber: | 4409604017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2007 | ||||||||
| LastUpdateDate: | 08/20/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | NP09106 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 3025372 | 05 | OH | MEDICAID | 2821781 | 05 | OH | MEDICAID |