Provider Demographics
NPI:1790977601
Name:LEO, KATHLEEN MARY
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARY
Last Name:LEO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 MORRISTOWN RD
Mailing Address - Street 2:
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-3580
Mailing Address - Country:US
Mailing Address - Phone:732-583-2135
Mailing Address - Fax:
Practice Address - Street 1:514 MORRISTOWN RD
Practice Address - Street 2:
Practice Address - City:MATAWAN
Practice Address - State:NJ
Practice Address - Zip Code:07747-3580
Practice Address - Country:US
Practice Address - Phone:732-583-2135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult