Provider Demographics
NPI:1609473750
Name:LEAK, ASIA VIANNA MACK
Entity Type:Individual
Prefix:
First Name:ASIA VIANNA
Middle Name:MACK
Last Name:LEAK
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 1:94 WEBSTER ST NE APT 2
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-4961
Mailing Address - Country:US
Mailing Address - Phone:404-934-5214
Mailing Address - Fax:
Practice Address - Street 1:529 14TH ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20045-1000
Practice Address - Country:US
Practice Address - Phone:202-986-5941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP9539101YM0800X
DCLGPC00541101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health