Provider Demographics
NPI:1356072862
Name:ABDULLAH, LAILLAH
Entity Type:Individual
Prefix:
First Name:LAILLAH
Middle Name:
Last Name:ABDULLAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 N STEWART ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:FL
Mailing Address - Zip Code:32351-2335
Mailing Address - Country:US
Mailing Address - Phone:850-875-2180
Mailing Address - Fax:850-807-2970
Practice Address - Street 1:15 N STEWART ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:FL
Practice Address - Zip Code:32351-2335
Practice Address - Country:US
Practice Address - Phone:850-875-2180
Practice Address - Fax:850-807-2970
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBT-22-220961OtherRBT CERTIFICATION