Provider Demographics
NPI:1326639022
Name:FANG, LEA (OTR)
Entity Type:Individual
Prefix:
First Name:LEA
Middle Name:
Last Name:FANG
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7208 ZEPHYR PL APT 1E
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63143-2300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1050 OLD DES PERES RD STE 40
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-1873
Practice Address - Country:US
Practice Address - Phone:302-993-6962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist