=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013686468
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEICA MARIE HAIRE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2021
-----------------------------------------------------
Last Update Date | 09/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7001 S HIGHWAY 94
-----------------------------------------------------
City | SAINT CHARLES
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63304-2201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-851-4700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 523 AUBURN TRACE LN
-----------------------------------------------------
City | SAINT PETERS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63376-1706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-777-3225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 2021029428
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------