Provider Demographics
NPI:1164026530
Name:SMITH, LEEANNA (COTA/L)
Entity Type:Individual
Prefix:MISS
First Name:LEEANNA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 34TH ST NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-2189
Mailing Address - Country:US
Mailing Address - Phone:740-258-0400
Mailing Address - Fax:
Practice Address - Street 1:619 6TH ST W
Practice Address - Street 2:
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470-1301
Practice Address - Country:US
Practice Address - Phone:218-732-3329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN202563224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant