Individual
LEIDYS HERRADA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
607 W OBISPO AVE, CLEWISTON, FL 33440-4326
(863) 677-4189
Mailing address
607 W OBISPO AVE, CLEWISTON, FL 33440-4326
(863) 677-4189
Taxonomy
Speciality
Code
Description
License number
State
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
Primary
5582-6-GA
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
015443100
—
FL
Enumeration date
01/30/2021
Last updated
01/30/2021
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