Provider Demographics
NPI:1962924183
Name:CARRASQUILLO- CORDERO, LEISHKA
Entity type:Individual
Prefix:
First Name:LEISHKA
Middle Name:
Last Name:CARRASQUILLO- CORDERO
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 1:5922 LOWGRASS RD
Mailing Address - Street 2:
Mailing Address - City:STEDMAN
Mailing Address - State:NC
Mailing Address - Zip Code:28391-4401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:345 DEVERS ST STE 101&102
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-4752
Practice Address - Country:US
Practice Address - Phone:910-400-9013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician