Provider Demographics
NPI:1184415903
Name:SPAIN, LETA OLIVIA
Entity type:Individual
Prefix:
First Name:LETA
Middle Name:OLIVIA
Last Name:SPAIN
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 COUNCIL ST APT 104
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-0389
Mailing Address - Country:US
Mailing Address - Phone:910-303-9602
Mailing Address - Fax:
Practice Address - Street 1:7649 MARKET ST UNIT 202
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411-9458
Practice Address - Country:US
Practice Address - Phone:910-981-1760
Practice Address - Fax:910-463-5495
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-13
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty