Provider Demographics
NPI:1164159331
Name:LEONELLI, BROOKE RITA (PHD)
Entity type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:RITA
Last Name:LEONELLI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:RITA
Other - Last Name:FUSCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19914 MSR TAMPA
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602
Mailing Address - Country:US
Mailing Address - Phone:315-772-6184
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVENUE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-2820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-06
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810008400103TC0700X, 171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical