Healthcare Provider Details

I. General information

NPI: 1205751880
Provider Name (Legal Business Name): LEISHKA MARIE AGOSTO DAVILA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR 568 KM 28.9 BARRIO PADILLA SECTOR LA COROZA
COROZAL PR
00783-7905
US

IV. Provider business mailing address

HC 5 BOX 11414
COROZAL PR
00783-9536
US

V. Phone/Fax

Practice location:
  • Phone: 787-399-8585
  • Fax:
Mailing address:
  • Phone: 787-399-8585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number008972
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: