Healthcare Provider Details

I. General information

NPI: 1841023520
Provider Name (Legal Business Name): LEANNA RAE TALIAFERRO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4204 GARDENDALE ST STE 107
SAN ANTONIO TX
78229-3138
US

IV. Provider business mailing address

6817 JOHN MARSHALL ST
SAN ANTONIO TX
78240-2925
US

V. Phone/Fax

Practice location:
  • Phone: 210-334-0108
  • Fax:
Mailing address:
  • Phone: 210-557-0510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number113768
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: