Provider Demographics
NPI:1801568779
Name:LEON-BERMEO, ALEXANDRA A
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:A
Last Name:LEON-BERMEO
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 1:15910 88TH AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-3928
Mailing Address - Country:US
Mailing Address - Phone:646-704-8372
Mailing Address - Fax:
Practice Address - Street 1:14015B SANFORD AVE FL 2
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-2557
Practice Address - Country:US
Practice Address - Phone:718-358-8288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-29
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY11616001104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker