Provider Demographics
NPI:1215394838
Name:DIOTALEVI, LEIGH (LISW-CP)
Entity Type:Individual
Prefix:
First Name:LEIGH
Middle Name:
Last Name:DIOTALEVI
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 RIVERWALK BLVD STE 11
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:SC
Mailing Address - Zip Code:29936-8191
Mailing Address - Country:US
Mailing Address - Phone:438-636-5017
Mailing Address - Fax:843-278-9198
Practice Address - Street 1:149 RIVERWALK BLVD STE 11
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:SC
Practice Address - Zip Code:29936-8191
Practice Address - Country:US
Practice Address - Phone:843-636-5017
Practice Address - Fax:843-278-9198
Is Sole Proprietor?:No
Enumeration Date:2016-01-27
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
SC115631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSW1478Medicaid