Provider Demographics
NPI:1013401371
Name:TALBOTT, LEANA SUE BAGGETT
Entity Type:Individual
Prefix:
First Name:LEANA
Middle Name:SUE BAGGETT
Last Name:TALBOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LEANA
Other - Middle Name:SUE
Other - Last Name:BAGGETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:421 W CONCHO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-6310
Mailing Address - Country:US
Mailing Address - Phone:325-500-8465
Mailing Address - Fax:
Practice Address - Street 1:421 W CONCHO AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-6310
Practice Address - Country:US
Practice Address - Phone:325-500-8465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TA0400X, 103TF0200X, 103TP2701X
TX37906103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy