Provider Demographics
NPI:1205533650
Name:THEODORE, LEON GEORGE
Entity type:Individual
Prefix:
First Name:LEON
Middle Name:GEORGE
Last Name:THEODORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4144 OFFICE PKWY APT 3203
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-8803
Mailing Address - Country:US
Mailing Address - Phone:407-547-6038
Mailing Address - Fax:
Practice Address - Street 1:4144 OFFICE PKWY APT 3203
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-8803
Practice Address - Country:US
Practice Address - Phone:407-547-6038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-15
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108805104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker