Provider Demographics
NPI:1679353841
Name:LEATHERWOOD, ALYSSA (RBT)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:LEATHERWOOD
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12060 ETRIS RD STE 200
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-1463
Mailing Address - Country:US
Mailing Address - Phone:770-557-0945
Mailing Address - Fax:
Practice Address - Street 1:12060 ETRIS RD STE 200
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-1463
Practice Address - Country:US
Practice Address - Phone:770-557-0945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-23-273601106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician