Provider Demographics
NPI:1568944320
Name:LEAVENGOOD, NATHAN P (LISW)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:P
Last Name:LEAVENGOOD
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:COSHOCTON
Mailing Address - State:OH
Mailing Address - Zip Code:43812-1655
Mailing Address - Country:US
Mailing Address - Phone:740-622-0033
Mailing Address - Fax:740-622-0210
Practice Address - Street 1:610 WALNUT ST
Practice Address - Street 2:
Practice Address - City:COSHOCTON
Practice Address - State:OH
Practice Address - Zip Code:43812-1655
Practice Address - Country:US
Practice Address - Phone:740-622-0033
Practice Address - Fax:740-622-0210
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2023-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1.22041081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0352267Medicaid