Provider Demographics
NPI:1194362947
Name:DE LEON, JOANNA MARIE DY (MS, LCPC)
Entity Type:Individual
Prefix:
First Name:JOANNA MARIE
Middle Name:DY
Last Name:DE LEON
Suffix:
Gender:F
Credentials:MS, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4615 E STATE ST STE 204
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2158
Mailing Address - Country:US
Mailing Address - Phone:815-708-9068
Mailing Address - Fax:
Practice Address - Street 1:4615 E STATE ST STE 204
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2158
Practice Address - Country:US
Practice Address - Phone:815-708-9068
Practice Address - Fax:779-970-5908
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-27
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YP2500X
IL180014142101YP2500X
IL178014740101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty