MEDICARE: NEW LEAF BEHAVIORAL SUPPORT LLC

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1851253322
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW LEAF BEHAVIORAL SUPPORT LLC

Provider Business Mailing Address
First Line	:	3291 ANDY LN
Second Line	:
City	:	CRESTVIEW
State	:	FL
Zip	:	32539-8625
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3291 ANDY LN
Second Line	:
City	:	CRESTVIEW
State	:	FL
Zip	:	32539-8625
Country	:	US
Telephone Number	:	850-603-0525
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DOMINIQUE GIESE
Credential	:	BCBA
Telephone Number	:	850-603-0525

Provider Enumeration Date	:	12/02/2025
Last Update Date	:	12/02/2025

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Directions to “NEW LEAF BEHAVIORAL SUPPORT LLC ” Practice Location

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