Provider Demographics
NPI:1083212328
Name:TANGUAY, LEO A
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:A
Last Name:TANGUAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 OLDE COUNTRY VILLAGE RD
Mailing Address - Street 2:
Mailing Address - City:LONDONDERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03053-3823
Mailing Address - Country:US
Mailing Address - Phone:207-450-1854
Mailing Address - Fax:
Practice Address - Street 1:47 OLDE COUNTRY VILLAGE RD
Practice Address - Street 2:
Practice Address - City:LONDONDERRY
Practice Address - State:NH
Practice Address - Zip Code:03053-3823
Practice Address - Country:US
Practice Address - Phone:207-450-1854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician