Provider Demographics
NPI:1013372044
Name:WETHERINGTON, LEAH MARIE
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:MARIE
Last Name:WETHERINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-2657
Mailing Address - Country:US
Mailing Address - Phone:386-451-0737
Mailing Address - Fax:
Practice Address - Street 1:58 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-2657
Practice Address - Country:US
Practice Address - Phone:386-451-0737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-17
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15-04445103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst