MEDICARE: ELAINE LEO D.O., M.H.A.

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	2084P0804X	Child & Adolescent Psychiatry Physician	02006610A	IN

General Provider Information

NPI Number	:	1902287667
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELAINE LEO D.O., M.H.A.

Provider Business Mailing Address
First Line	:	250 N SHADELAND AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-4959
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8820 S MERIDIAN ST STE 225
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46217-6064
Country	:	US
Telephone Number	:	317-944-8162
Fax Number	:	317-865-6930

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

Provider Enumeration Date	:	06/17/2015
Last Update Date	:	01/11/2022

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