Provider Demographics
NPI:1710916150
Name:LEO, CAROL M (LCSW-R)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:M
Last Name:LEO
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 DIXON RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-2132
Mailing Address - Country:US
Mailing Address - Phone:518-361-0289
Mailing Address - Fax:518-792-6235
Practice Address - Street 1:211 CHURCH ST
Practice Address - Street 2:CRAMER HOUSE
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-1003
Practice Address - Country:US
Practice Address - Phone:518-584-9030
Practice Address - Fax:518-581-1709
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070305-1101YM0800X
NY1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00639496Medicaid
NY03199997Medicaid
NYN6OU91Medicare PIN