Provider Demographics
NPI:1821806522
Name:MESA, LEONARDO (SR)
Entity type:Individual
Prefix:MR
First Name:LEONARDO
Middle Name:
Last Name:MESA
Suffix:
Gender:M
Credentials:SR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6470 SW 41ST ST APT 9
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-5153
Mailing Address - Country:US
Mailing Address - Phone:502-546-2829
Mailing Address - Fax:
Practice Address - Street 1:6470 SW 41ST ST APT 9
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-5153
Practice Address - Country:US
Practice Address - Phone:502-546-2829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-27
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24401854106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician