Provider Demographics
NPI:1689286163
Name:LEAHY, STEPHANIE M
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:LEAHY
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 1:11 E SUPERIOR ST STE 415
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-3008
Mailing Address - Country:US
Mailing Address - Phone:218-249-0595
Mailing Address - Fax:
Practice Address - Street 1:11 E SUPERIOR ST STE 415
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-3008
Practice Address - Country:US
Practice Address - Phone:218-249-0595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health