Provider Demographics
NPI:1730546862
Name:DOMUS LEONUM LLC
Entity type:Organization
Organization Name:DOMUS LEONUM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ARPANA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIVDASANI
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:917-528-0694
Mailing Address - Street 1:1551 FORUM PLACE
Mailing Address - Street 2:BUILDING 400 SUITE D/E
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-5505
Mailing Address - Country:US
Mailing Address - Phone:917-528-0694
Mailing Address - Fax:
Practice Address - Street 1:1551 FORUM PLACE
Practice Address - Street 2:BUILDING 400 SUITE D/E
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-5505
Practice Address - Country:US
Practice Address - Phone:917-528-0694
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-20
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME49592101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty