Provider Demographics
NPI:1780816124
Name:MCINTOSH-LEACH, LISA MICHELLE (LPT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MICHELLE
Last Name:MCINTOSH-LEACH
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60431-8433
Mailing Address - Country:US
Mailing Address - Phone:815-730-1370
Mailing Address - Fax:815-730-1517
Practice Address - Street 1:3320 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60431-8433
Practice Address - Country:US
Practice Address - Phone:815-730-1370
Practice Address - Fax:815-730-1517
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-19
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070008898251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health