Provider Demographics
NPI:1215106984
Name:STURDIVANT, LEON HARLIE SR (EDD)
Entity type:Individual
Prefix:DR
First Name:LEON
Middle Name:HARLIE
Last Name:STURDIVANT
Suffix:SR
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 DONLORA DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-6015
Mailing Address - Country:US
Mailing Address - Phone:336-854-1718
Mailing Address - Fax:336-854-1718
Practice Address - Street 1:808 MYSTIC DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-5726
Practice Address - Country:US
Practice Address - Phone:336-854-1718
Practice Address - Fax:336-854-1718
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL041732323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC9500744861Medicaid