=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508092966
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEAH MARIA ANTOINTTE WIGGINS- MARSHALLL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2009
-----------------------------------------------------
Last Update Date | 05/29/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5579 S HANNIBAL WAY
-----------------------------------------------------
City | CENTENNIAL
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80015-4277
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-617-4357
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5579 S HANNIBAL WAY
-----------------------------------------------------
City | CENTENNIAL
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80015-4277
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-617-4357
-----------------------------------------------------
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 | 588134
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------