Provider Demographics
NPI:1043746407
Name:STEIN, LEIA KATHERINE
Entity Type:Individual
Prefix:
First Name:LEIA
Middle Name:KATHERINE
Last Name:STEIN
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 1:544 STONEFIELD DR
Mailing Address - Street 2:
Mailing Address - City:SMITHTON
Mailing Address - State:IL
Mailing Address - Zip Code:62285-1560
Mailing Address - Country:US
Mailing Address - Phone:618-670-9069
Mailing Address - Fax:
Practice Address - Street 1:785 WALL ST STE 200
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1959
Practice Address - Country:US
Practice Address - Phone:618-670-9069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-04
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180012041101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty