Provider Demographics
NPI:1932634730
Name:MINOR, KLEO LETICIA
Entity Type:Individual
Prefix:
First Name:KLEO
Middle Name:LETICIA
Last Name:MINOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:LETICIA
Other - Last Name:MINOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:144 ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-4928
Mailing Address - Country:US
Mailing Address - Phone:614-309-3971
Mailing Address - Fax:
Practice Address - Street 1:124 CAPULET DR
Practice Address - Street 2:UNIT 102
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-4537
Practice Address - Country:US
Practice Address - Phone:904-429-3859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-29
Last Update Date:2017-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician