Healthcare Provider Details

I. General information

NPI: 1598891681
Provider Name (Legal Business Name): LEELA HASAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 10/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 W ALTO ROAD
KOKOMO IN
46902
US

IV. Provider business mailing address

PO BOX 6459
KOKOMO IN
46904-6459
US

V. Phone/Fax

Practice location:
  • Phone: 765-453-7422
  • Fax: 765-453-3773
Mailing address:
  • Phone: 765-453-7422
  • Fax: 765-453-3773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34002266A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35000151A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: