Basic Information
| Provider Information | |||||||||
| NPI: | 1679558183 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEITE | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | H | ||||||||
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| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1220 E ELM ST | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458042850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192242632 | ||||||||
| FaxNumber: | 4192222731 | ||||||||
| Practice Location | |||||||||
| Address1: | 1220 E ELM ST | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458042850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192242632 | ||||||||
| FaxNumber: | 4192222731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | NM04988 | OH | Y | Other Service Providers | Midwife |
ID Information
| ID | Type | State | Issuer | Description | 2492128 | 05 | OH | MEDICAID |