Provider Demographics
NPI:1003037136
Name:HIDEY, LEISA MARIE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:LEISA
Middle Name:MARIE
Last Name:HIDEY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6203 WOODCREST DR.
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043
Mailing Address - Country:US
Mailing Address - Phone:410-379-0194
Mailing Address - Fax:
Practice Address - Street 1:700 N. 40TH ST.
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211
Practice Address - Country:US
Practice Address - Phone:410-235-8860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA01399224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant