Provider Demographics
NPI:1174865463
Name:PENA DELGADO, LEONARDO
Entity Type:Individual
Prefix:
First Name:LEONARDO
Middle Name:
Last Name:PENA DELGADO
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 1:29 FAIRVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-2900
Mailing Address - Country:US
Mailing Address - Phone:516-303-4403
Mailing Address - Fax:
Practice Address - Street 1:29 FAIRVIEW BLVD
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-2900
Practice Address - Country:US
Practice Address - Phone:516-303-4403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-25
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023542235Z00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program