Provider Demographics
NPI:1184728115
Name:LEAVELL, MARK D (MSW, LCSW)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:D
Last Name:LEAVELL
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:205 SE 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64014-3103
Mailing Address - Country:US
Mailing Address - Phone:816-224-0172
Mailing Address - Fax:816-220-8163
Practice Address - Street 1:3210 GILLHAM RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64109-1714
Practice Address - Country:US
Practice Address - Phone:816-531-7737
Practice Address - Fax:816-531-7738
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030198921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO495353310Medicaid