Provider Demographics
NPI:1891842936
Name:LEACH, BEVAN LEE (LMSW)
Entity Type:Individual
Prefix:MR
First Name:BEVAN
Middle Name:LEE
Last Name:LEACH
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 SANDY POINT DR
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-2523
Mailing Address - Country:US
Mailing Address - Phone:616-796-0385
Mailing Address - Fax:
Practice Address - Street 1:1150 E SHERMAN BLVD STE 1125
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1894
Practice Address - Country:US
Practice Address - Phone:231-672-3723
Practice Address - Fax:231-672-6787
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010165681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical