Provider Demographics
NPI:1659064905
Name:LEAKE, BETTY J
Entity Type:Individual
Prefix:MRS
First Name:BETTY
Middle Name:J
Last Name:LEAKE
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:PO BOX 1205
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:SC
Mailing Address - Zip Code:29706-1210
Mailing Address - Country:US
Mailing Address - Phone:704-808-0378
Mailing Address - Fax:
Practice Address - Street 1:151 CENTER ST # A
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:SC
Practice Address - Zip Code:29706-2704
Practice Address - Country:US
Practice Address - Phone:704-808-0378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health