Provider Demographics
NPI:1942772074
Name:LEACH, SHANNON T (BA CMS)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:T
Last Name:LEACH
Suffix:
Gender:M
Credentials:BA CMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11110 LITTLE SPRING BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-5066
Mailing Address - Country:US
Mailing Address - Phone:502-712-8905
Mailing Address - Fax:
Practice Address - Street 1:4835 POPLAR LEVEL RD STE 110
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-2906
Practice Address - Country:US
Practice Address - Phone:502-443-5273
Practice Address - Fax:502-631-9660
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-31
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty