Healthcare Provider Details

I. General information

NPI: 1679665764
Provider Name (Legal Business Name): SUSAN K LEOPOLD OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 E 4TH ST
OTTAWA OH
45875-1545
US

IV. Provider business mailing address

9452 ROAD 11
OTTAWA OH
45875-9606
US

V. Phone/Fax

Practice location:
  • Phone: 419-523-9337
  • Fax: 419-523-6323
Mailing address:
  • Phone: 419-447-7203
  • Fax: 419-447-5577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number063522
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: