Provider Demographics
NPI:1811413750
Name:LEELING, CARRIE JANE (LMSW)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:JANE
Last Name:LEELING
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:JANE
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 1387
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-1387
Mailing Address - Country:US
Mailing Address - Phone:208-415-0299
Mailing Address - Fax:
Practice Address - Street 1:740 MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:KELLOGG
Practice Address - State:ID
Practice Address - Zip Code:83837-2693
Practice Address - Country:US
Practice Address - Phone:208-783-1267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-22
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-36779104100000X
IDLCSW-407911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID36779OtherSTATE LICENSE