Provider Demographics
NPI:1891130068
Name:LEARY, AMY E (LCSW, LCAS)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:E
Last Name:LEARY
Suffix:
Gender:F
Credentials:LCSW, LCAS
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 9373
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28299-9373
Mailing Address - Country:US
Mailing Address - Phone:704-293-9177
Mailing Address - Fax:
Practice Address - Street 1:5105 MONROE RD
Practice Address - Street 2:SUITE E
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-7825
Practice Address - Country:US
Practice Address - Phone:704-293-9177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-01
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20341101YA0400X
NCC0080811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)