Provider Demographics
NPI:1306868765
Name:LEIBFORTH, TERESA N (OTR/L)
Entity type:Individual
Prefix:MS
First Name:TERESA
Middle Name:N
Last Name:LEIBFORTH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3803 NW 47TH TER
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-5992
Mailing Address - Country:US
Mailing Address - Phone:352-376-5197
Mailing Address - Fax:
Practice Address - Street 1:335 NE 10TH AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-4456
Practice Address - Country:US
Practice Address - Phone:352-795-5552
Practice Address - Fax:352-795-7751
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 8392225XP0200X
FLOT8392222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ073POtherBLUE CROSS BLUE SHIELD
FL890815000Medicaid