Provider Demographics
NPI:1740475318
Name:LEISING, MARY MARGARET (OTR)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:MARGARET
Last Name:LEISING
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 1:2817 NEW PINERY RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-9257
Mailing Address - Country:US
Mailing Address - Phone:608-745-5063
Mailing Address - Fax:
Practice Address - Street 1:2817 NEW PINERY RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9257
Practice Address - Country:US
Practice Address - Phone:608-745-5063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3711-026174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3711-026OtherST OF WI LICENSING