MEDICARE: LESLIE MBANEFO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1649102070
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE MBANEFO

Provider Business Mailing Address
First Line	:	175 BELGROVE DR
Second Line	:
City	:	KEARNY
State	:	NJ
Zip	:	07032-1507
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12240 INDIAN CREEK CT
Second Line	:
City	:	BELTSVILLE
State	:	MD
Zip	:	20705-1242
Country	:	US
Telephone Number	:	201-979-1336
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2026
Last Update Date	:	06/01/2026

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Directions to “ LESLIE MBANEFO ” Practice Location

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