Provider Demographics
NPI:1740582709
Name:SMITH-CLOONAN, LEIGH C (LBSW)
Entity Type:Individual
Prefix:
First Name:LEIGH
Middle Name:C
Last Name:SMITH-CLOONAN
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 BARTLETT ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-7005
Mailing Address - Country:US
Mailing Address - Phone:907-235-0302
Mailing Address - Fax:907-235-0810
Practice Address - Street 1:203 W PIONEER AVE STE 1
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7527
Practice Address - Country:US
Practice Address - Phone:907-235-0302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-24
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK952171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPCG519AMedicaid
AKCMG799Medicaid
AKHC2563Medicaid
AKHH2711Medicaid
AKNA3799Medicaid
AKMS0272Medicaid
AKNA3799Medicaid