Provider Demographics
NPI:1134177330
Name:CHARLEMAGNE, LEILA TERESITA (PSYD)
Entity type:Individual
Prefix:
First Name:LEILA
Middle Name:TERESITA
Last Name:CHARLEMAGNE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 8TH AVE W STE 101
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:FL
Mailing Address - Zip Code:34221-4737
Mailing Address - Country:US
Mailing Address - Phone:941-845-4905
Mailing Address - Fax:941-845-4963
Practice Address - Street 1:3601 FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33137-3795
Practice Address - Country:US
Practice Address - Phone:305-567-6611
Practice Address - Fax:305-576-0008
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7299103TC0700X
FLPY 7299103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPY7299OtherLICENSE
FL768803200Medicaid
FLU7436VMedicare PIN