Provider Demographics
NPI:1306508452
Name:WOOTEN, LEIGH ELIZABETH
Entity type:Individual
Prefix:MRS
First Name:LEIGH
Middle Name:ELIZABETH
Last Name:WOOTEN
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 1:13139 ROYAL FERN DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-7723
Mailing Address - Country:US
Mailing Address - Phone:321-278-6163
Mailing Address - Fax:
Practice Address - Street 1:13139 ROYAL FERN DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-7723
Practice Address - Country:US
Practice Address - Phone:321-278-6163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL802103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool