Healthcare Provider Details

I. General information

NPI: 1407490295
Provider Name (Legal Business Name): SAMANTHA DENISE LEBO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2019
Last Update Date: 11/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3640 COLONEL GLENN HWY
DAYTON OH
45435-0002
US

IV. Provider business mailing address

1954 AMELIA CT
MIAMISBURG OH
45342-5472
US

V. Phone/Fax

Practice location:
  • Phone: 937-775-1000
  • Fax:
Mailing address:
  • Phone: 561-221-8452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: