Provider Demographics
NPI:1710873088
Name:LEASURE, MARICIELO
Entity type:Individual
Prefix:
First Name:MARICIELO
Middle Name:
Last Name:LEASURE
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 1:610 FOXCROFT DR
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-4433
Mailing Address - Country:US
Mailing Address - Phone:801-472-2434
Mailing Address - Fax:
Practice Address - Street 1:305 W PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-4413
Practice Address - Country:US
Practice Address - Phone:443-300-6905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-14
Last Update Date:2025-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP16596101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health