Provider Demographics
NPI:1689374092
Name:ROBERTS, LEAH J (RCSWI)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:J
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:RCSWI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3164 LAKE ELLEN DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-3618
Mailing Address - Country:US
Mailing Address - Phone:813-922-1090
Mailing Address - Fax:
Practice Address - Street 1:1200 W PLATT ST STE 204
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-2136
Practice Address - Country:US
Practice Address - Phone:813-922-1090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW174161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLISW17416OtherDEPARTMENT OF HEALTH