Provider Demographics
NPI:1376087726
Name:DE LEON, MYRNA TANIA (LMSW)
Entity Type:Individual
Prefix:MS
First Name:MYRNA
Middle Name:TANIA
Last Name:DE LEON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 LONGFELLOW AVE APT 4B
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10460-5413
Mailing Address - Country:US
Mailing Address - Phone:137-571-4112
Mailing Address - Fax:
Practice Address - Street 1:2510 WESTCHESTER AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-3585
Practice Address - Country:US
Practice Address - Phone:171-859-7555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-05
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY096089104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker