Provider Demographics
NPI:1790156651
Name:GAINES, LEISA
Entity Type:Individual
Prefix:MS
First Name:LEISA
Middle Name:
Last Name:GAINES
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 1:4242 LA HWY 19 SUITE 3B
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791
Mailing Address - Country:US
Mailing Address - Phone:225-757-5699
Mailing Address - Fax:225-757-4845
Practice Address - Street 1:4242 LA HWY 19 SUITE 3B
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791
Practice Address - Country:US
Practice Address - Phone:225-757-5699
Practice Address - Fax:225-757-4845
Is Sole Proprietor?:No
Enumeration Date:2015-10-16
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health