Healthcare Provider Details

I. General information

NPI: 1396240826
Provider Name (Legal Business Name): TIARA LEE LEAVITT- CELESTINA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 03/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 W OAKLAND PARK BLVD FL 2
WILTON MANORS FL
33311-1600
US

IV. Provider business mailing address

6100 BLUE LAGOON DR STE 400
MIAMI FL
33126-2080
US

V. Phone/Fax

Practice location:
  • Phone: 954-327-4060
  • Fax:
Mailing address:
  • Phone: 305-398-6100
  • Fax: 305-757-2387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: