Healthcare Provider Details

I. General information

NPI: 1679215776
Provider Name (Legal Business Name): LEAF BEHAVIOR SUPPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2022
Last Update Date: 04/09/2022
Certification Date: 04/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3577 BRANNON DR
VIRGINIA BEACH VA
23456-6913
US

IV. Provider business mailing address

3577 BRANNON DR
VIRGINIA BEACH VA
23456-6913
US

V. Phone/Fax

Practice location:
  • Phone: 757-971-1414
  • Fax: 757-937-0287
Mailing address:
  • Phone: 757-971-1414
  • Fax: 757-937-0287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code224ZE0001X
TaxonomyEnvironmental Modification Occupational Therapy Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: WHITNEY KING
Title or Position: CEO
Credential: PBS-F
Phone: 757-971-1414