Provider Demographics
NPI:1235634445
Name:LEIMBACH, MARY JO (MA, LPC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JO
Last Name:LEIMBACH
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 SEAVERS RD
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:TN
Mailing Address - Zip Code:38358-6176
Mailing Address - Country:US
Mailing Address - Phone:217-917-5764
Mailing Address - Fax:
Practice Address - Street 1:42 SEAVERS RD
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:TN
Practice Address - Zip Code:38358-6176
Practice Address - Country:US
Practice Address - Phone:217-917-5764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.013811101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional