Provider Demographics
NPI:1275907560
Name:PACE, LEAH L (LMSW)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:L
Last Name:PACE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4571 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-2917
Mailing Address - Country:US
Mailing Address - Phone:318-424-8735
Mailing Address - Fax:318-424-8739
Practice Address - Street 1:4571 N MARKET ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107
Practice Address - Country:US
Practice Address - Phone:318-424-8735
Practice Address - Fax:318-424-8739
Is Sole Proprietor?:No
Enumeration Date:2015-11-24
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13911104100000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1417252230Medicaid