Basic Information
| Provider Information | |||||||||
| NPI: | 1134177330 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHARLEMAGNE | ||||||||
| FirstName: | LEILA | ||||||||
| MiddleName: | TERESITA | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 8TH AVE W STE 101 | ||||||||
| Address2: | |||||||||
| City: | PALMETTO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342214737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9418454905 | ||||||||
| FaxNumber: | 9418454963 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 FEDERAL HWY | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331373795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055676611 | ||||||||
| FaxNumber: | 3055760008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 02/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PY7299 | FL | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | PY 7299 | FL | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | PY7299 | 01 | FL | LICENSE | OTHER | 768803200 | 05 | FL | MEDICAID |