Healthcare Provider Details

I. General information

NPI: 1699498725
Provider Name (Legal Business Name): LEILANI MARIE VICTOR LCAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2022
Last Update Date: 09/23/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4419 3RD AVE
BRONX NY
10457-2562
US

IV. Provider business mailing address

4419 3RD AVE
BRONX NY
10457-2562
US

V. Phone/Fax

Practice location:
  • Phone: 718-364-7700
  • Fax:
Mailing address:
  • Phone: 718-364-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number002712
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: