Provider Demographics
NPI:1710204292
Name:LEESBURG PSYCHOLOGY
Entity Type:Organization
Organization Name:LEESBURG PSYCHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:R
Authorized Official - Last Name:BAEZ-ROJAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:352-787-7144
Mailing Address - Street 1:8529 US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34788-4021
Mailing Address - Country:US
Mailing Address - Phone:352-787-7144
Mailing Address - Fax:352-450-7600
Practice Address - Street 1:8529 US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34788-4021
Practice Address - Country:US
Practice Address - Phone:352-787-7144
Practice Address - Fax:352-450-7600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-23
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4794103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59515OtherBLUE CROSS AND BLUE SHIELD OF FLORIDA
FL59515OtherBLUE CROSS AND BLUE SHIELD OF FLORIDA