Provider Demographics
NPI:1700119070
Name:SWEET, LESLIE (COTA)
Entity Type:Individual
Prefix:MISS
First Name:LESLIE
Middle Name:
Last Name:SWEET
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10637 SEILER RD
Mailing Address - Street 2:APT 409
Mailing Address - City:NEW HAVEN
Mailing Address - State:IN
Mailing Address - Zip Code:46774-9357
Mailing Address - Country:US
Mailing Address - Phone:260-385-7484
Mailing Address - Fax:
Practice Address - Street 1:2837 E DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1668
Practice Address - Country:US
Practice Address - Phone:260-497-0328
Practice Address - Fax:260-497-0904
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-17
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001690A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant