Provider Demographics
NPI:1154795615
Name:ANTUNES, LEAH (CMA)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:ANTUNES
Suffix:
Gender:F
Credentials:CMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 MOCKINGBIRD DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29073-8739
Mailing Address - Country:US
Mailing Address - Phone:803-237-4103
Mailing Address - Fax:
Practice Address - Street 1:110 MOCKINGBIRD DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29073-8739
Practice Address - Country:US
Practice Address - Phone:803-237-4103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-20
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC47-5267829302F00000X
SC100295992172A00000X, 347C00000X
SC475267829251V00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
No172A00000XOther Service ProvidersDriver
No347C00000XTransportation ServicesPrivate Vehicle
No251V00000XAgenciesVoluntary or Charitable
No251S00000XAgenciesCommunity/Behavioral Health