Provider Demographics
NPI:1942513478
Name:LEACH, EDA MONICA (SOCIAL WORKER)
Entity Type:Individual
Prefix:MS
First Name:EDA
Middle Name:MONICA
Last Name:LEACH
Suffix:
Gender:F
Credentials:SOCIAL WORKER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1746 DEN HERTOG ST SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-3337
Mailing Address - Country:US
Mailing Address - Phone:616-531-1142
Mailing Address - Fax:616-328-2883
Practice Address - Street 1:1746 DEN HERTOG ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-3337
Practice Address - Country:US
Practice Address - Phone:616-531-1142
Practice Address - Fax:616-328-2883
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-26
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010781131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical