Provider Demographics
NPI:1609341551
Name:LEACH, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:LEACH
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 1:162J GROVE ST
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-2640
Mailing Address - Country:US
Mailing Address - Phone:760-873-6533
Mailing Address - Fax:760-873-3277
Practice Address - Street 1:162J GROVE ST
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-2640
Practice Address - Country:US
Practice Address - Phone:760-873-6533
Practice Address - Fax:760-873-3277
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor