Provider Demographics
NPI:1114399664
Name:NETTLES, LEAH
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:NETTLES
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 1:20620 US HIGHWAY 129
Mailing Address - Street 2:
Mailing Address - City:O BRIEN
Mailing Address - State:FL
Mailing Address - Zip Code:32071-3161
Mailing Address - Country:US
Mailing Address - Phone:386-688-5162
Mailing Address - Fax:
Practice Address - Street 1:260 S MARION AVE STE 135
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-7000
Practice Address - Country:US
Practice Address - Phone:352-373-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-23
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant