Provider Demographics
NPI:1821864851
Name:LEEWAY ENTERPRISE
Entity Type:Organization
Organization Name:LEEWAY ENTERPRISE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RODGER
Authorized Official - Middle Name:MOULTRIE
Authorized Official - Last Name:LEE
Authorized Official - Suffix:II
Authorized Official - Credentials:MSC/CC, LPC, BHP
Authorized Official - Phone:520-304-3655
Mailing Address - Street 1:1014 N COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-4239
Mailing Address - Country:US
Mailing Address - Phone:520-304-3655
Mailing Address - Fax:
Practice Address - Street 1:1014 N COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-4239
Practice Address - Country:US
Practice Address - Phone:520-304-3655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-30
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health