Provider Demographics
NPI:1669747630
Name:VARGHESE, LEESA
Entity type:Individual
Prefix:
First Name:LEESA
Middle Name:
Last Name:VARGHESE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1851 MERLIN RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-3841
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:85 OLD EAGLE SCHOOL RD
Practice Address - Street 2:200
Practice Address - City:STRAFFORD
Practice Address - State:PA
Practice Address - Zip Code:19087-2556
Practice Address - Country:US
Practice Address - Phone:267-241-4942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-09
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health