Healthcare Provider Details

I. General information

NPI: 1699596254
Provider Name (Legal Business Name): LEAH MARIE DAYTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E HIGHLAND MALL BLVD
AUSTIN TX
78752-3775
US

IV. Provider business mailing address

320 LEA LN
WIMBERLEY TX
78676-4907
US

V. Phone/Fax

Practice location:
  • Phone: 512-961-5575
  • Fax:
Mailing address:
  • Phone: 512-775-2036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number95842
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: