Provider Demographics
NPI:1457852279
Name:LEIBY, MARILYN LOUISE (OTR)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:LOUISE
Last Name:LEIBY
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 1:1264 S ROYSTON RD
Mailing Address - Street 2:
Mailing Address - City:EATON RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:48827-9091
Mailing Address - Country:US
Mailing Address - Phone:517-256-1950
Mailing Address - Fax:
Practice Address - Street 1:530 BEECH ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-1016
Practice Address - Country:US
Practice Address - Phone:517-543-2940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201000951225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1437171485Medicaid