Healthcare Provider Details

I. General information

NPI: 1184586992
Provider Name (Legal Business Name): THERESA LETO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 LAKE AVE STE 27
FORT WAYNE IN
46805-5428
US

IV. Provider business mailing address

3030 LAKE AVE STE 27
FORT WAYNE IN
46805-5428
US

V. Phone/Fax

Practice location:
  • Phone: 260-267-5631
  • Fax:
Mailing address:
  • Phone: 260-267-5631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31004072A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: