Provider Demographics
NPI:1619602968
Name:SOLIS, LEANDRA DANIELLE
Entity Type:Individual
Prefix:
First Name:LEANDRA
Middle Name:DANIELLE
Last Name:SOLIS
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 1:108 BIRCH CIR
Mailing Address - Street 2:
Mailing Address - City:PORT WENTWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:31407-3322
Mailing Address - Country:US
Mailing Address - Phone:512-496-8536
Mailing Address - Fax:
Practice Address - Street 1:108 BIRCH CIR
Practice Address - Street 2:
Practice Address - City:PORT WENTWORTH
Practice Address - State:GA
Practice Address - Zip Code:31407-3322
Practice Address - Country:US
Practice Address - Phone:512-496-8536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA171M00000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No171M00000XOther Service ProvidersCase Manager/Care Coordinator