Healthcare Provider Details

I. General information

NPI: 1164159331
Provider Name (Legal Business Name): BROOKE RITA LEONELLI PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BROOKE RITA FUSCO

II. Dates (important events)

Enumeration Date: 08/06/2022
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19914 MSR TAMPA
FORT DRUM NY
13602
US

IV. Provider business mailing address

19914 MSR TAMPA
FORT DRUM NY
13602
US

V. Phone/Fax

Practice location:
  • Phone: 315-772-6184
  • Fax:
Mailing address:
  • Phone: 315-772-6184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810008400
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: