Provider Demographics
NPI:1861009516
Name:LEONARD, CRYSTAL ODESSA
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ODESSA
Last Name:LEONARD
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 1:183 SEABREEZE CT
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-5572
Mailing Address - Country:US
Mailing Address - Phone:317-847-8836
Mailing Address - Fax:
Practice Address - Street 1:183 SEABREEZE CT
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-5572
Practice Address - Country:US
Practice Address - Phone:317-847-8836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA103TE1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA261QS100XOtherN/A