Provider Demographics
NPI:1417641986
Name:LEONARD, TIFFANY JULIANA
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:JULIANA
Last Name:LEONARD
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 1:5 OLIVE CT
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-1923
Mailing Address - Country:US
Mailing Address - Phone:631-655-3652
Mailing Address - Fax:
Practice Address - Street 1:4770 SUNRISE HWY STE 102
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA PARK
Practice Address - State:NY
Practice Address - Zip Code:11762-2911
Practice Address - Country:US
Practice Address - Phone:516-406-8991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-06
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP119572101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health