Provider Demographics
NPI:1851605901
Name:GONGOLA, LEAH CHRISTINE (PHD, BCBA-D)
Entity Type:Individual
Prefix:DR
First Name:LEAH
Middle Name:CHRISTINE
Last Name:GONGOLA
Suffix:
Gender:F
Credentials:PHD, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15445 CHARDON WINDSOR RD
Mailing Address - Street 2:
Mailing Address - City:HUNTSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44046-8728
Mailing Address - Country:US
Mailing Address - Phone:440-313-8636
Mailing Address - Fax:
Practice Address - Street 1:15445 CHARDON WINDSOR RD
Practice Address - Street 2:
Practice Address - City:HUNTSBURG
Practice Address - State:OH
Practice Address - Zip Code:44046-8728
Practice Address - Country:US
Practice Address - Phone:440-313-8636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-31
Last Update Date:2010-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1-09-5195103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst