Provider Demographics
NPI:1568136273
Name:MINDNICH, LEIGH KOELL
Entity Type:Individual
Prefix:MS
First Name:LEIGH
Middle Name:KOELL
Last Name:MINDNICH
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 1:6850 MORRO RD
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-4123
Mailing Address - Country:US
Mailing Address - Phone:510-317-1444
Mailing Address - Fax:
Practice Address - Street 1:6850 MORRO RD
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-4123
Practice Address - Country:US
Practice Address - Phone:510-317-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAASW115519104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program