Healthcare Provider Details

I. General information

NPI: 1649875121
Provider Name (Legal Business Name): LESLIANN SAMANTHA JEAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8785 SW 165TH AVE STE 104
MIAMI FL
33193-5827
US

IV. Provider business mailing address

3840 SW 11TH ST
FORT LAUDERDALE FL
33312-3408
US

V. Phone/Fax

Practice location:
  • Phone: 786-206-6500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: