Healthcare Provider Details

I. General information

NPI: 1639634850
Provider Name (Legal Business Name): KRISTA LEETH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2019
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5563 FAR HILLS AVE
DAYTON OH
45429-2225
US

IV. Provider business mailing address

5563 FAR HILLS AVE
DAYTON OH
45429-2225
US

V. Phone/Fax

Practice location:
  • Phone: 937-291-2300
  • Fax:
Mailing address:
  • Phone: 937-291-2300
  • Fax: 937-291-2303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.175016
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: