Provider Demographics
NPI:1760735807
Name:LEARY, MARTHA LEAH (LCSWA)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:LEAH
Last Name:LEARY
Suffix:
Gender:F
Credentials:LCSWA
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 29158
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28229-9158
Mailing Address - Country:US
Mailing Address - Phone:704-965-2364
Mailing Address - Fax:
Practice Address - Street 1:1400 HARDING PL
Practice Address - Street 2:SUITE 250
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2924
Practice Address - Country:US
Practice Address - Phone:704-965-2364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0059731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical