Provider Demographics
NPI:1851583744
Name:THERESA H LIETE CNM INC
Entity Type:Organization
Organization Name:THERESA H LIETE CNM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:DICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-224-2632
Mailing Address - Street 1:1220 E ELM ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-2898
Mailing Address - Country:US
Mailing Address - Phone:419-224-2632
Mailing Address - Fax:419-222-2731
Practice Address - Street 1:1220 E ELM ST
Practice Address - Street 2:SUITE 204
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-2898
Practice Address - Country:US
Practice Address - Phone:419-224-2632
Practice Address - Fax:419-222-2731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNM04988367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2492128Medicaid