Provider Demographics
NPI:1720525397
Name:LEGER, MICHAELLE
Entity type:Individual
Prefix:
First Name:MICHAELLE
Middle Name:
Last Name:LEGER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 ACE OUTLAW AVE
Mailing Address - Street 2:
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33570-6051
Mailing Address - Country:US
Mailing Address - Phone:754-254-9296
Mailing Address - Fax:
Practice Address - Street 1:2329 E WT HARRIS BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-5186
Practice Address - Country:US
Practice Address - Phone:704-529-9090
Practice Address - Fax:704-529-9002
Is Sole Proprietor?:No
Enumeration Date:2017-01-20
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1932367638Medicaid