Provider Demographics
NPI:1164058442
Name:LEIVA, CONZUELO (LAC)
Entity Type:Individual
Prefix:
First Name:CONZUELO
Middle Name:
Last Name:LEIVA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 69TH ST
Mailing Address - Street 2:
Mailing Address - City:GUTTENBERG
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-3339
Mailing Address - Country:US
Mailing Address - Phone:551-274-3876
Mailing Address - Fax:
Practice Address - Street 1:127 69TH ST
Practice Address - Street 2:
Practice Address - City:GUTTENBERG
Practice Address - State:NJ
Practice Address - Zip Code:07093-3339
Practice Address - Country:US
Practice Address - Phone:551-274-3876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00350200101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ37AC00350200OtherLICENSE