Healthcare Provider Details

I. General information

NPI: 1831632231
Provider Name (Legal Business Name): LEONEL LASANTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2016
Last Update Date: 07/26/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE 2 KM 11.8 EDIFICIO CENTURION PISO 3
BAYAMON PR
00961
US

IV. Provider business mailing address

120 MAPLE ST
SPRINGFIELD MA
01103-2203
US

V. Phone/Fax

Practice location:
  • Phone: 787-704-0705
  • Fax:
Mailing address:
  • Phone: 413-846-0445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number7010
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: