Healthcare Provider Details

I. General information

NPI: 1245893403
Provider Name (Legal Business Name): ADRIANNE VYASULU LEONHARDT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2019
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3230 ARDEN CIR
MELBOURNE FL
32934-8772
US

IV. Provider business mailing address

3230 ARDEN CIR
MELBOURNE FL
32934-8772
US

V. Phone/Fax

Practice location:
  • Phone: 954-261-6143
  • Fax:
Mailing address:
  • Phone: 954-261-6143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15350
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: