Provider Demographics
NPI:1679323745
Name:LEAL MOLLINEDO, MARY LEYDI
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LEYDI
Last Name:LEAL MOLLINEDO
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 1:31 NE 12TH AVE UNIT 31
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030-6213
Mailing Address - Country:US
Mailing Address - Phone:305-528-0187
Mailing Address - Fax:
Practice Address - Street 1:31 NE 12TH AVE UNIT 31
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-6213
Practice Address - Country:US
Practice Address - Phone:305-528-0187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-335211106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty