Provider Demographics
NPI:1134916497
Name:LEACH, MICHELLE RAE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RAE
Last Name:LEACH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68502-3559
Mailing Address - Country:US
Mailing Address - Phone:402-475-5161
Mailing Address - Fax:
Practice Address - Street 1:2202 S 11TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68502-3559
Practice Address - Country:US
Practice Address - Phone:402-475-5161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-21
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 104100000X
CPSS-267175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker