Provider Demographics
NPI:1144995838
Name:LEFTRIDGE, TAYELL (CHW)
Entity type:Individual
Prefix:MRS
First Name:TAYELL
Middle Name:
Last Name:LEFTRIDGE
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 ROOSEVELT RD STE 200-6
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-0971
Mailing Address - Country:US
Mailing Address - Phone:219-615-0095
Mailing Address - Fax:
Practice Address - Street 1:2600 ROOSEVELT RD STE 200-6
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-0971
Practice Address - Country:US
Practice Address - Phone:219-615-0095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300007737Medicaid