Provider Demographics
NPI:1336645829
Name:LEAL, MIRTHALA (MED; LPA)
Entity Type:Individual
Prefix:MRS
First Name:MIRTHALA
Middle Name:
Last Name:LEAL
Suffix:
Gender:F
Credentials:MED; LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4709 CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78501-3796
Mailing Address - Country:US
Mailing Address - Phone:956-467-2717
Mailing Address - Fax:
Practice Address - Street 1:1901 S 24TH AVE
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-6533
Practice Address - Country:US
Practice Address - Phone:956-289-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34021103TM1800X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities