Healthcare Provider Details

I. General information

NPI: 1528884723
Provider Name (Legal Business Name): LONICK LEANDRE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2024
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10128 LANCASHIRE DR
JACKSONVILLE FL
32219-4366
US

IV. Provider business mailing address

10128 LANCASHIRE DR
JACKSONVILLE FL
32219-4366
US

V. Phone/Fax

Practice location:
  • Phone: 904-990-9659
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: