Provider Demographics
NPI:1427587799
Name:LEAK, ALYSIA (LMFTA)
Entity Type:Individual
Prefix:
First Name:ALYSIA
Middle Name:
Last Name:LEAK
Suffix:
Gender:F
Credentials:LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1554 UNION RD STE C
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-5581
Mailing Address - Country:US
Mailing Address - Phone:704-869-2047
Mailing Address - Fax:
Practice Address - Street 1:1554 UNION RD STE C
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-5581
Practice Address - Country:US
Practice Address - Phone:704-869-2047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2018-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12006A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist