Basic Information
| Provider Information | |||||||||
| NPI: | 1053743013 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REED | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BCABA | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1855 W HIBISCUS BLVD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329012622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213454232 | ||||||||
| FaxNumber: | 3217656434 | ||||||||
| Practice Location | |||||||||
| Address1: | 1855 W HIBISCUS BLVD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329012622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213454232 | ||||||||
| FaxNumber: | 3217656434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2013 | ||||||||
| LastUpdateDate: | 07/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 0-13-5524 | FL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 0-13-5524 | 01 | FL | BCABA | OTHER |