Provider Demographics
NPI:1063244150
Name:LEON, MARIAM
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:LEON
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 1:2013 49TH TER SW
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34116-5741
Mailing Address - Country:US
Mailing Address - Phone:239-234-3764
Mailing Address - Fax:
Practice Address - Street 1:2013 49TH TER SW
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34116-5741
Practice Address - Country:US
Practice Address - Phone:239-234-3764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB1046040106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician