Provider Demographics
NPI:1447978846
Name:ANAGHO, LEROY
Entity type:Individual
Prefix:
First Name:LEROY
Middle Name:
Last Name:ANAGHO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 W WASHINGTON ST APT 4091
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85288-0940
Mailing Address - Country:US
Mailing Address - Phone:901-230-6745
Mailing Address - Fax:
Practice Address - Street 1:1003 W WASHINGTON ST APT 4091
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85288-0940
Practice Address - Country:US
Practice Address - Phone:901-230-6745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 171400000X, 171M00000X
NC317178163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171400000XOther Service ProvidersHealth & Wellness Coach
No171M00000XOther Service ProvidersCase Manager/Care Coordinator