Provider Demographics
NPI:1013742402
Name:LEACH, HEATHER L (LCSW)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:LEACH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 ALGONQUIN DR
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-1228
Mailing Address - Country:US
Mailing Address - Phone:608-225-7544
Mailing Address - Fax:
Practice Address - Street 1:429 GAMMON PL STE 200
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1053
Practice Address - Country:US
Practice Address - Phone:608-824-7243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6682-123101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health