Healthcare Provider Details

I. General information

NPI: 1336452994
Provider Name (Legal Business Name): SHAREA ANGELA LEAVY HAD & SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHAREA ANGELA MINES HAD & SLP

II. Dates (important events)

Enumeration Date: 07/23/2010
Last Update Date: 10/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 N CHARLES ST PPE SUITE 601
BALTIMORE MD
21204-6800
US

IV. Provider business mailing address

6565 N CHARLES ST PPE SUITE 601
BALTIMORE MD
21204-6800
US

V. Phone/Fax

Practice location:
  • Phone: 410-821-5151
  • Fax: 410-823-8309
Mailing address:
  • Phone: 410-821-5151
  • Fax: 410-823-8309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number01195
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: