Healthcare Provider Details

I. General information

NPI: 1609514603
Provider Name (Legal Business Name): LORI LEISS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2022
Last Update Date: 05/20/2022
Certification Date: 05/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2317 E HOME RD
SPRINGFIELD OH
45503-2520
US

IV. Provider business mailing address

2317 E HOME RD
SPRINGFIELD OH
45503-2520
US

V. Phone/Fax

Practice location:
  • Phone: 937-342-4378
  • Fax: 937-399-9070
Mailing address:
  • Phone: 937-342-4378
  • Fax: 937-399-9070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.180581
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: