Provider Demographics
NPI:1386338010
Name:LEISE, KERRY KRISTINE
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:KRISTINE
Last Name:LEISE
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 1:9529 W FM 93
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:TX
Mailing Address - Zip Code:76513-8321
Mailing Address - Country:US
Mailing Address - Phone:254-444-3949
Mailing Address - Fax:
Practice Address - Street 1:9623 BRYCE DR # 19
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-3218
Practice Address - Country:US
Practice Address - Phone:512-641-4020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst