Provider Demographics
NPI:1407131634
Name:KLEIN, LEAH RAQUEL (MS)
Entity Type:Individual
Prefix:MS
First Name:LEAH
Middle Name:RAQUEL
Last Name:KLEIN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1366 S 1140 E
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-6640
Mailing Address - Country:US
Mailing Address - Phone:801-372-0545
Mailing Address - Fax:
Practice Address - Street 1:814 BAMBERGER DR
Practice Address - Street 2:SUITE A
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2165
Practice Address - Country:US
Practice Address - Phone:801-772-0202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT49056016004101YP2500X
UT24537103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool