Provider Demographics
NPI:1619294634
Name:EDA LEACH
Entity Type:Organization
Organization Name:EDA LEACH
Other - Org Name:EDA LEACH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:EDA
Authorized Official - Middle Name:MONICA
Authorized Official - Last Name:LEACH
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:616-531-1142
Mailing Address - Street 1:1746 DEN HERTOG ST SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-3337
Mailing Address - Country:US
Mailing Address - Phone:616-531-1142
Mailing Address - Fax:616-531-1142
Practice Address - Street 1:1746 DEN HERTOG ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-3337
Practice Address - Country:US
Practice Address - Phone:616-531-1142
Practice Address - Fax:616-531-1142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-29
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI638107811104100000X, 302F00000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI638107811Medicare Oscar/Certification