Healthcare Provider Details

I. General information

NPI: 1700217767
Provider Name (Legal Business Name): CARLA A. LEONARD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2013
Last Update Date: 12/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 REGAL LN
CROWNSVILLE MD
21032-1404
US

IV. Provider business mailing address

1206 REGAL LN
CROWNSVILLE MD
21032-1404
US

V. Phone/Fax

Practice location:
  • Phone: 410-903-2806
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License NumberR094983
License Number StateMD

VIII. Authorized Official

Name: CARLA LEONARD
Title or Position: NURSE PSYCHOTHERAPIST
Credential:
Phone: 410-903-2806