Provider Demographics
NPI:1679719876
Name:LEIBA, WENDY
Entity Type:Individual
Prefix:MS
First Name:WENDY
Middle Name:
Last Name:LEIBA
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:WENDY
Other - Middle Name:
Other - Last Name:LEIBA-MATOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2139 JUDITH PL
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-7012
Mailing Address - Country:US
Mailing Address - Phone:407-406-2577
Mailing Address - Fax:
Practice Address - Street 1:1800 PEMBROOK DRIVE
Practice Address - Street 2:SUITE 300
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32810-1512
Practice Address - Country:US
Practice Address - Phone:407-406-2577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-18
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1679719876Medicaid