Provider Demographics
NPI:1962810457
Name:SPEAKMAN, EVA
Entity type:Individual
Prefix:
First Name:EVA
Middle Name:
Last Name:SPEAKMAN
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 1:208 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45135-9660
Mailing Address - Country:US
Mailing Address - Phone:937-780-2082
Mailing Address - Fax:
Practice Address - Street 1:208 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:OH
Practice Address - Zip Code:45135-9660
Practice Address - Country:US
Practice Address - Phone:937-780-1081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3004386320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3004386OtherOHIO FAMILY JOB AND SERVICES - MY CARE OHIO