Provider Demographics
NPI:1881225985
Name:LEAKE, KIMBERLY FLOWER (LMSW)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:FLOWER
Last Name:LEAKE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 DOGWOOD HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764-1709
Mailing Address - Country:US
Mailing Address - Phone:516-243-3715
Mailing Address - Fax:
Practice Address - Street 1:27 DOGWOOD HOLLOW LN
Practice Address - Street 2:
Practice Address - City:MILLER PLACE
Practice Address - State:NY
Practice Address - Zip Code:11764-1709
Practice Address - Country:US
Practice Address - Phone:516-243-3715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY065757-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker