Provider Demographics
NPI:1073092623
Name:LEON, GRACE (OTA/L)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:LEON
Suffix:
Gender:F
Credentials:OTA/L
Other - Prefix:
Other - First Name:GRACIELA
Other - Middle Name:MONTENEGRO
Other - Last Name:LEON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:GRACIELA MONTENEGRO
Mailing Address - Street 1:9994 NW 5TH LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-4004
Mailing Address - Country:US
Mailing Address - Phone:786-683-7633
Mailing Address - Fax:
Practice Address - Street 1:9400 SW 137TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-1434
Practice Address - Country:US
Practice Address - Phone:305-385-8290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA9790224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant