Provider Demographics
NPI:1851509756
Name:HERMANSON-FAUL, LEAH S
Entity Type:Individual
Prefix:MRS
First Name:LEAH
Middle Name:S
Last Name:HERMANSON-FAUL
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:LEAH
Other - Middle Name:S
Other - Last Name:FAUL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:309 2ND ST E
Mailing Address - Street 2:
Mailing Address - City:BOTTINEAU
Mailing Address - State:ND
Mailing Address - Zip Code:58318-1104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:309 2ND ST E
Practice Address - Street 2:
Practice Address - City:BOTTINEAU
Practice Address - State:ND
Practice Address - Zip Code:58318-1104
Practice Address - Country:US
Practice Address - Phone:701-228-3743
Practice Address - Fax:701-228-3365
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND766225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND52068Medicaid