=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457027856
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEEMU GARYU
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2021
-----------------------------------------------------
Last Update Date | 08/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8980 ZACHARY LN N
-----------------------------------------------------
City | MAPLE GROVE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55369-4018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-767-7222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6054 W BROADWAY AVE APT 8
-----------------------------------------------------
City | NEW HOPE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55428-2858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-601-2813
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------