Provider Demographics
NPI:1316039621
Name:LEIVA, MIRENTXU (PSYD)
Entity Type:Individual
Prefix:
First Name:MIRENTXU
Middle Name:
Last Name:LEIVA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4141 NAUTILUS DR
Mailing Address - Street 2:7-H
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33140-2839
Mailing Address - Country:US
Mailing Address - Phone:305-401-2085
Mailing Address - Fax:
Practice Address - Street 1:25 SE 2ND AVE
Practice Address - Street 2:STE 1240
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33131-1606
Practice Address - Country:US
Practice Address - Phone:305-401-2085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5798103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54369BMedicare ID - Type Unspecified