Provider Demographics
NPI:1558592881
Name:LEAKE, KIP
Entity Type:Individual
Prefix:MR
First Name:KIP
Middle Name:
Last Name:LEAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3468 MT DIABLO BLVD
Mailing Address - Street 2:SUITE B201
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-3957
Mailing Address - Country:US
Mailing Address - Phone:925-297-5196
Mailing Address - Fax:
Practice Address - Street 1:3468 MT DIABLO BLVD
Practice Address - Street 2:SUITE B201
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3957
Practice Address - Country:US
Practice Address - Phone:925-297-5196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-04
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83312106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist