Provider Demographics
NPI:1205556396
Name:LEASURE, KATHRYN KELEEN (PHD)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:KELEEN
Last Name:LEASURE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 PARKBROOK CIR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-8915
Mailing Address - Country:US
Mailing Address - Phone:850-290-4052
Mailing Address - Fax:
Practice Address - Street 1:267 JOHN KNOX RD STE 114
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-6628
Practice Address - Country:US
Practice Address - Phone:850-807-9801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY11520103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist