Provider Demographics
NPI: | 1922487321 |
---|---|
Name: | LEIGH BOSTIC LLC |
Entity Type: | Organization |
Organization Name: | LEIGH BOSTIC LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | SOLE MEMBER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | LEIGH |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BOSTIC |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 864-298-8026 |
Mailing Address - Street 1: | 706 S ALMOND DR |
Mailing Address - Street 2: | |
Mailing Address - City: | SIMPSONVILLE |
Mailing Address - State: | SC |
Mailing Address - Zip Code: | 29681-3347 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 864-430-0475 |
Mailing Address - Fax: | 864-298-8032 |
Practice Address - Street 1: | 110 MANLY ST |
Practice Address - Street 2: | |
Practice Address - City: | GREENVILLE |
Practice Address - State: | SC |
Practice Address - Zip Code: | 29601-3025 |
Practice Address - Country: | US |
Practice Address - Phone: | 864-298-8026 |
Practice Address - Fax: | 864-298-8032 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2015-05-19 |
Last Update Date: | 2015-05-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
SC | 5459 | 1041C0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Single Specialty |