Provider Demographics
NPI:1689275869
Name:LEATHERMAN, STACEE (BCBA)
Entity Type:Individual
Prefix:
First Name:STACEE
Middle Name:
Last Name:LEATHERMAN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 36TH ST
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-3449
Mailing Address - Country:US
Mailing Address - Phone:309-798-1780
Mailing Address - Fax:
Practice Address - Street 1:9902 SWANSON BLVD
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-6932
Practice Address - Country:US
Practice Address - Phone:847-322-9377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst