Healthcare Provider Details

I. General information

NPI: 1013401371
Provider Name (Legal Business Name): LEANA SUE BAGGETT TALBOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LEANA SUE BAGGETT

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 W CONCHO AVE
SAN ANGELO TX
76903-6310
US

IV. Provider business mailing address

421 W CONCHO AVE
SAN ANGELO TX
76903-6310
US

V. Phone/Fax

Practice location:
  • Phone: 325-500-8465
  • Fax:
Mailing address:
  • Phone: 325-500-8465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number37906
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: