Provider Demographics
NPI:1881720878
Name:LEON, GRACIELA
Entity type:Individual
Prefix:
First Name:GRACIELA
Middle Name:
Last Name:LEON
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 1:207 SULPHUR SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77801-3134
Mailing Address - Country:US
Mailing Address - Phone:979-260-3910
Mailing Address - Fax:
Practice Address - Street 1:207 SULPHUR SPRINGS RD
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77801-3134
Practice Address - Country:US
Practice Address - Phone:979-260-3910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4077106H00000X
TX11735101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2907LCMedicare UPIN