Basic Information
| Provider Information | |||||||||
| NPI: | 1093871188 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEONARD | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BROADWAY | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PH.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 602368 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193500351 | ||||||||
| FaxNumber: | 9193507687 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 NEW BERN AVE | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193508000 | ||||||||
| FaxNumber: | 9193502995 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2006 | ||||||||
| LastUpdateDate: | 03/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | PSY2859 | NC | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103T00000X | PSY2859 | NC | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | PSY2859 | NC | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | D9059 | 01 | NC | MEDCOST | OTHER | 6000628 | 05 | NC | MEDICAID | 1093871188 | 05 | NC | MEDICAID | 786099000 | 01 | NC | MAGELLAN | OTHER | 0508313 | 01 | NC | CIGNA | OTHER | 046G0 | 01 | NC | BCBS | OTHER |