Provider Demographics
NPI:1164273082
Name:LEEP, EMILY BELLE
Entity Type:Individual
Prefix:MISS
First Name:EMILY
Middle Name:BELLE
Last Name:LEEP
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 1:688 WHITEMARSH AVE
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-7127
Mailing Address - Country:US
Mailing Address - Phone:386-457-3536
Mailing Address - Fax:
Practice Address - Street 1:555 W GRANADA BLVD STE A11
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-9488
Practice Address - Country:US
Practice Address - Phone:386-254-8788
Practice Address - Fax:386-226-2076
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-335194106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty