Provider Demographics
NPI:1063648673
Name:LEACH, MELISSA WALTER STEPHAN
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:WALTER STEPHAN
Last Name:LEACH
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 1:3042 SUMMERCREST DR
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-5103
Mailing Address - Country:US
Mailing Address - Phone:352-871-1274
Mailing Address - Fax:
Practice Address - Street 1:3042 SUMMERCREST DR
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-5103
Practice Address - Country:US
Practice Address - Phone:352-871-1274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-09
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
TX4220103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst