Provider Demographics
NPI:1639059033
Name:LEO, BENJAMIN ROBERT (NP)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ROBERT
Last Name:LEO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1928 GRAFTON SHOP RD
Mailing Address - Street 2:
Mailing Address - City:FOREST HILL
Mailing Address - State:MD
Mailing Address - Zip Code:21050-2418
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1928 GRAFTON SHOP RD
Practice Address - Street 2:
Practice Address - City:FOREST HILL
Practice Address - State:MD
Practice Address - Zip Code:21050-2418
Practice Address - Country:US
Practice Address - Phone:302-547-5120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-05
Last Update Date:2025-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR269431363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health