Healthcare Provider Details

I. General information

NPI: 1225305055
Provider Name (Legal Business Name): LEIGH N ONTIVEROS MT-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2011
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S CULLEN AVE STE 118
EVANSVILLE IN
47715-4137
US

IV. Provider business mailing address

4258 N 4TH AVE
EVANSVILLE IN
47710-3524
US

V. Phone/Fax

Practice location:
  • Phone: 812-491-9400
  • Fax:
Mailing address:
  • Phone: 443-617-9706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: