Provider Demographics
NPI:1922218569
Name:PRINCE, LEONIE S
Entity Type:Individual
Prefix:
First Name:LEONIE
Middle Name:S
Last Name:PRINCE
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 1:765 E ROUTE 70
Mailing Address - Street 2:BUILDING A
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-2341
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:765 E ROUTE 70
Practice Address - Street 2:BUILDING A
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2341
Practice Address - Country:US
Practice Address - Phone:973-625-7007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA089555002084P0804X
NY2532702084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry