Provider Demographics
NPI:1578344131
Name:LEISCH, DAWN
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:
Last Name:LEISCH
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 1:515 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:WIMBERLEY
Mailing Address - State:TX
Mailing Address - Zip Code:78676-9169
Mailing Address - Country:US
Mailing Address - Phone:310-923-3654
Mailing Address - Fax:
Practice Address - Street 1:515 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:WIMBERLEY
Practice Address - State:TX
Practice Address - Zip Code:78676-9169
Practice Address - Country:US
Practice Address - Phone:310-923-3654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX202779106H00000X
CA82030106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist