Provider Demographics
NPI:1578200853
Name:LEID, MARK ANTHONY
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:LEID
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-1440
Mailing Address - Country:US
Mailing Address - Phone:239-634-1308
Mailing Address - Fax:
Practice Address - Street 1:309 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-1440
Practice Address - Country:US
Practice Address - Phone:239-634-1308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services