Provider Demographics
NPI:1912350125
Name:HOUSTON, LEA (LMT)
Entity type:Individual
Prefix:
First Name:LEA
Middle Name:
Last Name:HOUSTON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 72
Mailing Address - Street 2:
Mailing Address - City:GUSTAVUS
Mailing Address - State:AK
Mailing Address - Zip Code:99826-0072
Mailing Address - Country:US
Mailing Address - Phone:907-723-9466
Mailing Address - Fax:
Practice Address - Street 1:1920 GUSTAVUS RD
Practice Address - Street 2:SALMON RIVER CENTER BLD A
Practice Address - City:GUSTAVUS
Practice Address - State:AK
Practice Address - Zip Code:99826
Practice Address - Country:US
Practice Address - Phone:907-723-9466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-22
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK104373174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist