Provider Demographics
NPI:1699172536
Name:MYERHOLTZ, LEANDRA MARIE
Entity type:Individual
Prefix:
First Name:LEANDRA
Middle Name:MARIE
Last Name:MYERHOLTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 BARTSON RD
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-9672
Mailing Address - Country:US
Mailing Address - Phone:419-332-5524
Mailing Address - Fax:419-332-7581
Practice Address - Street 1:675 BARTSON RD
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-9672
Practice Address - Country:US
Practice Address - Phone:419-332-5524
Practice Address - Fax:419-332-7581
Is Sole Proprietor?:No
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS1201377104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker