Provider Demographics
NPI:1285131177
Name:LEIVA, CAROLINA A
Entity type:Individual
Prefix:
First Name:CAROLINA
Middle Name:A
Last Name:LEIVA
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:PO BOX 646
Mailing Address - Street 2:
Mailing Address - City:BURDETT
Mailing Address - State:NY
Mailing Address - Zip Code:14818-0646
Mailing Address - Country:US
Mailing Address - Phone:607-288-2332
Mailing Address - Fax:
Practice Address - Street 1:6245 CAYUTAVILLE RD
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:NY
Practice Address - Zip Code:14805-9752
Practice Address - Country:US
Practice Address - Phone:607-288-2332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-09
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010505101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health