Provider Demographics
NPI:1881231942
Name:DE LEON, ILSE SUCELY
Entity Type:Individual
Prefix:
First Name:ILSE
Middle Name:SUCELY
Last Name:DE LEON
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 1:170 DAVIDSON HWY STE 201
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-4255
Mailing Address - Country:US
Mailing Address - Phone:980-209-6328
Mailing Address - Fax:704-298-4206
Practice Address - Street 1:170 DAVIDSON HWY STE 201
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-4255
Practice Address - Country:US
Practice Address - Phone:980-209-6328
Practice Address - Fax:704-298-4206
Is Sole Proprietor?:No
Enumeration Date:2019-12-06
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA15411101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health