Provider Demographics
NPI:1669767653
Name:TASILLO, LEIGH ANN ZIMMERMAN (PSY D)
Entity type:Individual
Prefix:
First Name:LEIGH ANN
Middle Name:ZIMMERMAN
Last Name:TASILLO
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 UNIONVILLE-INDIAN TRAIL RD.
Mailing Address - Street 2:SUITE B3
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079
Mailing Address - Country:US
Mailing Address - Phone:704-765-2062
Mailing Address - Fax:704-684-4324
Practice Address - Street 1:124 UNIONVILLE-INDIAN TRAIL RD.
Practice Address - Street 2:SUITE B3
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079
Practice Address - Country:US
Practice Address - Phone:704-765-2062
Practice Address - Fax:704-684-4324
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4293103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical