Provider Demographics
NPI:1093472623
Name:HIGGINBOTHAM, LEILA
Entity Type:Individual
Prefix:
First Name:LEILA
Middle Name:
Last Name:HIGGINBOTHAM
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 1:431 OBERLIN AVE
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44052-1474
Mailing Address - Country:US
Mailing Address - Phone:440-225-4400
Mailing Address - Fax:
Practice Address - Street 1:431 OBERLIN AVE
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44052-1474
Practice Address - Country:US
Practice Address - Phone:440-225-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-18
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH601413470521385H00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0465779Medicaid