Provider Demographics
NPI:1336694520
Name:LEACH, MATTHEW ALLAN (LCSWA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:ALLAN
Last Name:LEACH
Suffix:
Gender:M
Credentials:LCSWA
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Mailing Address - Street 1:284 EXECUTIVE PARK DR
Mailing Address - Street 2:STE 100
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1833
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:704-939-1173
Practice Address - Street 1:1190 W ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-2818
Practice Address - Country:US
Practice Address - Phone:704-296-6200
Practice Address - Fax:704-296-4668
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NCP0105711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1336694520Medicaid
NC19NG5OtherBCBS