Healthcare Provider Details

I. General information

NPI: 1417467424
Provider Name (Legal Business Name): LESLIE DANIELLE COUDEN DILEO LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2017
Last Update Date: 10/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 KINGSLEY LAKE DR
SAINT AUGUSTINE FL
32092-3043
US

IV. Provider business mailing address

109 BLUESTONE RIVER WAY
ST AUGUSTINE FL
32092-1925
US

V. Phone/Fax

Practice location:
  • Phone: 502-386-3647
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH12739
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: