Provider Demographics
NPI:1811305287
Name:LIEBHART, LESA
Entity type:Individual
Prefix:
First Name:LESA
Middle Name:
Last Name:LIEBHART
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 1:16912 W WESTERN RESERVE RD
Mailing Address - Street 2:
Mailing Address - City:BERLIN CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:44401-9705
Mailing Address - Country:US
Mailing Address - Phone:330-428-3433
Mailing Address - Fax:330-584-7630
Practice Address - Street 1:16912 W WESTERN RESERVE RD
Practice Address - Street 2:
Practice Address - City:BERLIN CENTER
Practice Address - State:OH
Practice Address - Zip Code:44401-9705
Practice Address - Country:US
Practice Address - Phone:330-428-3433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2940545Medicaid