Provider Demographics
NPI:1407394596
Name:LEAK, DE'ARA
Entity Type:Individual
Prefix:
First Name:DE'ARA
Middle Name:
Last Name:LEAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4703 GREENHILL AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-5743
Mailing Address - Country:US
Mailing Address - Phone:443-720-9053
Mailing Address - Fax:
Practice Address - Street 1:7175 COLUMBIA GATEWAY DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-2534
Practice Address - Country:US
Practice Address - Phone:888-344-5977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician