Provider Demographics
NPI:1316720501
Name:FARGO, LEAH (BA)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:FARGO
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3418 44TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-2902
Mailing Address - Country:US
Mailing Address - Phone:612-770-3250
Mailing Address - Fax:
Practice Address - Street 1:275 4TH ST E STE 301
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-1771
Practice Address - Country:US
Practice Address - Phone:651-318-0109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist