Provider Demographics
NPI:1093871188
Name:LEONARD, SUSAN ELIZABETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:LEONARD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:ELIZABETH
Other - Last Name:BROADWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 602368
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2368
Mailing Address - Country:US
Mailing Address - Phone:919-350-0351
Mailing Address - Fax:919-350-7687
Practice Address - Street 1:3000 NEW BERN AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1231
Practice Address - Country:US
Practice Address - Phone:919-350-8000
Practice Address - Fax:919-350-2995
Is Sole Proprietor?:No
Enumeration Date:2006-12-31
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCPSY2859103G00000X, 103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCD9059OtherMEDCOST
NC6000628Medicaid
NC1093871188Medicaid
NC786099000OtherMAGELLAN
NC0508313OtherCIGNA
NC046G0OtherBCBS