Provider Demographics
NPI:1477886380
Name:DETHERAGE, LEANN (LPCA)
Entity Type:Individual
Prefix:
First Name:LEANN
Middle Name:
Last Name:DETHERAGE
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 105
Mailing Address - Street 2:
Mailing Address - City:LORETTO
Mailing Address - State:KY
Mailing Address - Zip Code:40037-0105
Mailing Address - Country:US
Mailing Address - Phone:270-699-1811
Mailing Address - Fax:
Practice Address - Street 1:3244 WIMSATT ROAD
Practice Address - Street 2:
Practice Address - City:LORETTO
Practice Address - State:KY
Practice Address - Zip Code:40037
Practice Address - Country:US
Practice Address - Phone:270-699-1811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-09
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0911101Y00000X
KY6254P363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor