MEDICARE: LEKRESIA OUTLAW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker
2	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1598477234
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEKRESIA OUTLAW

Provider Business Mailing Address
First Line	:	5646 COUNTESS DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-7412
Country	:	US
Telephone Number	:	260-602-5229
Fax Number	:

Provider Business Practice Location Address
First Line	:	5646 COUNTESS DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-7412
Country	:	US
Telephone Number	:	260-602-5229
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2022
Last Update Date	:	12/14/2022

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Directions to “ LEKRESIA OUTLAW ” Practice Location

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