Provider Demographics
NPI:1124330238
Name:FENNEMA, LEAH MARIE (MS, BCBA)
Entity type:Individual
Prefix:MRS
First Name:LEAH
Middle Name:MARIE
Last Name:FENNEMA
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 W NORTHWEST HWY
Mailing Address - Street 2:114-1045
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-6989
Mailing Address - Country:US
Mailing Address - Phone:817-366-7299
Mailing Address - Fax:
Practice Address - Street 1:2150 W NORTHWEST HWY
Practice Address - Street 2:114-1045
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-6989
Practice Address - Country:US
Practice Address - Phone:817-366-7299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-06
Last Update Date:2016-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-15-20774103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst