Provider Demographics
NPI:1356661532
Name:LEAKE, JOSEPH SHERMAN JR (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:SHERMAN
Last Name:LEAKE
Suffix:JR
Gender:M
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-1428
Mailing Address - Country:US
Mailing Address - Phone:270-692-9559
Mailing Address - Fax:270-692-9236
Practice Address - Street 1:312 W HIGH ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1428
Practice Address - Country:US
Practice Address - Phone:270-692-9559
Practice Address - Fax:270-692-9236
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPSYPST00219033103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100349680Medicaid