Provider Demographics
NPI:1417410267
Name:LEATHERWOOD BROCK, CARY ELIZABETH (LPC)
Entity Type:Individual
Prefix:
First Name:CARY
Middle Name:ELIZABETH
Last Name:LEATHERWOOD BROCK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 CASH RD NE
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30701-9717
Mailing Address - Country:US
Mailing Address - Phone:706-676-0262
Mailing Address - Fax:
Practice Address - Street 1:1414 DUG GAP RD
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-5007
Practice Address - Country:US
Practice Address - Phone:706-279-0405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LPC010903101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health