Provider Demographics
NPI:1013686468
Name:HAIRE, LEICA MARIE
Entity Type:Individual
Prefix:
First Name:LEICA
Middle Name:MARIE
Last Name:HAIRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 AUBURN TRACE LN
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-1706
Mailing Address - Country:US
Mailing Address - Phone:502-777-3225
Mailing Address - Fax:
Practice Address - Street 1:7001 S HIGHWAY 94
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63304-2201
Practice Address - Country:US
Practice Address - Phone:636-851-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021029428225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist