Provider Demographics
NPI:1457653941
Name:LEAKS, REGINA N
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:N
Last Name:LEAKS
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 1:5537 BLEAUX AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-0737
Mailing Address - Country:US
Mailing Address - Phone:479-872-5580
Mailing Address - Fax:479-872-5581
Practice Address - Street 1:824 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-3316
Practice Address - Country:US
Practice Address - Phone:870-234-0495
Practice Address - Fax:870-234-9481
Is Sole Proprietor?:No
Enumeration Date:2010-12-03
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor