Provider Demographics
NPI:1194360412
Name:LEISTNER, TIMOTHY (EDD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:LEISTNER
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3911 HOLLYWOOD BLVD # 3201
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-6795
Mailing Address - Country:US
Mailing Address - Phone:954-639-7345
Mailing Address - Fax:
Practice Address - Street 1:3911 HOLLYWOOD BLVD # 3201
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6795
Practice Address - Country:US
Practice Address - Phone:954-639-7345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-11
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health