Provider Demographics
NPI:1851491005
Name:LEACH, WAYNE (LISW)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:LEACH
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35000 CHARDON RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-9012
Mailing Address - Country:US
Mailing Address - Phone:440-951-5600
Mailing Address - Fax:440-951-1293
Practice Address - Street 1:35000 CHARDON RD
Practice Address - Street 2:SUITE 210
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-9012
Practice Address - Country:US
Practice Address - Phone:440-951-5600
Practice Address - Fax:440-951-1293
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-81511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSW32062Medicare PIN