Provider Demographics
NPI:1790208601
Name:PEDEVILLANO, LEAH
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:PEDEVILLANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 ADAM WALKER DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-4509
Mailing Address - Country:US
Mailing Address - Phone:203-305-7839
Mailing Address - Fax:
Practice Address - Street 1:14 VERNON ST
Practice Address - Street 2:
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950-3920
Practice Address - Country:US
Practice Address - Phone:203-305-7839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-23
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1240741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty