Healthcare Provider Details

I. General information

NPI: 1033049341
Provider Name (Legal Business Name): BEATRIZ LEYVA OMAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 WILSON AVE
MADISON IN
47250-2135
US

IV. Provider business mailing address

724 W 3RD ST
MADISON IN
47250-3117
US

V. Phone/Fax

Practice location:
  • Phone: 812-265-8226
  • Fax:
Mailing address:
  • Phone: 717-984-1360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-537746
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: