Provider Demographics
NPI:1821695651
Name:DESMOULIN, LEONA
Entity Type:Individual
Prefix:
First Name:LEONA
Middle Name:
Last Name:DESMOULIN
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:FLUSHING HOSPITAL MEDICAL CENTER
Mailing Address - Street 2:4500 PARSONS BLVD.
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355
Mailing Address - Country:US
Mailing Address - Phone:718-670-4416
Mailing Address - Fax:
Practice Address - Street 1:FLUSHING HOSPITAL MEDICAL CENTER
Practice Address - Street 2:4500 PARSONS BLVD.
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355
Practice Address - Country:US
Practice Address - Phone:718-670-4416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY35717101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00243843Medicaid