Provider Demographics
NPI:1982406740
Name:LEONARD, JUSTINE MELISANDE (MFC36954)
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:MELISANDE
Last Name:LEONARD
Suffix:
Gender:
Credentials:MFC36954
Other - Prefix:
Other - First Name:JUSTINE
Other - Middle Name:MELISANDE
Other - Last Name:POLEVOY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MFC36954
Mailing Address - Street 1:37 LEDGES LN
Mailing Address - Street 2:
Mailing Address - City:FREEDOM
Mailing Address - State:ME
Mailing Address - Zip Code:04941-3247
Mailing Address - Country:US
Mailing Address - Phone:510-710-2301
Mailing Address - Fax:
Practice Address - Street 1:37 LEDGES LN
Practice Address - Street 2:
Practice Address - City:FREEDOM
Practice Address - State:ME
Practice Address - Zip Code:04941-3247
Practice Address - Country:US
Practice Address - Phone:510-710-2301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-25
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36954106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty