Provider Demographics
NPI:1083172142
Name:LEITH, GARRICK
Entity Type:Individual
Prefix:
First Name:GARRICK
Middle Name:
Last Name:LEITH
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 1:1547 30TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-5149
Mailing Address - Country:US
Mailing Address - Phone:218-287-4338
Mailing Address - Fax:
Practice Address - Street 1:1635 43RD ST S STE 105
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3579
Practice Address - Country:US
Practice Address - Phone:701-412-2973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDL64103K00000X
174400000X
1-20-44702103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No174400000XOther Service ProvidersSpecialist