Provider Demographics
NPI:1336647346
Name:MORTAZAVI, LEILA ELIZABETH (LCSW)
Entity Type:Individual
Prefix:
First Name:LEILA
Middle Name:ELIZABETH
Last Name:MORTAZAVI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10824 RUCKLE ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46280-1031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:720 ESKEANZI AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5166
Practice Address - Country:US
Practice Address - Phone:317-880-7666
Practice Address - Fax:317-880-0448
Is Sole Proprietor?:No
Enumeration Date:2018-01-24
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical