Provider Demographics
NPI:1194261214
Name:DELEON, TOMMY RUSSELL II (BS)
Entity type:Individual
Prefix:MR
First Name:TOMMY
Middle Name:RUSSELL
Last Name:DELEON
Suffix:II
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3887 OKEMOS RD STE A1
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3663
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3887 OKEMOS RD STE A1
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3663
Practice Address - Country:US
Practice Address - Phone:517-803-6506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRBT-16-25659106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician