Provider Demographics
NPI:1407463359
Name:LEACH, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:LEACH
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 1:285 LINDEN DR
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4565
Mailing Address - Country:US
Mailing Address - Phone:937-231-4694
Mailing Address - Fax:
Practice Address - Street 1:285 LINDEN DR
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4565
Practice Address - Country:US
Practice Address - Phone:937-231-4694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03587543747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0358754Medicaid