Basic Information
| Provider Information | |||||||||
| NPI: | 1659372100 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEON | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | ALEXANDER | ||||||||
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| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8400 LOUISIANA ST | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197571928 | ||||||||
| FaxNumber: | 2197571950 | ||||||||
| Practice Location | |||||||||
| Address1: | 8555 TAFT ST | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197694005 | ||||||||
| FaxNumber: | 2197692508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 39000758A | IN | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 000000360223 | 01 | IN | ANTHEM BLUECROSS | OTHER |