Provider Demographics
NPI:1396475422
Name:ZOLLER, LEIGH DOUGLAS
Entity type:Individual
Prefix:
First Name:LEIGH
Middle Name:DOUGLAS
Last Name:ZOLLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 JENNINGS CT APT 2307
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606
Mailing Address - Country:US
Mailing Address - Phone:706-315-8955
Mailing Address - Fax:
Practice Address - Street 1:1090 FOUNDERS BLVD STE B
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6163
Practice Address - Country:US
Practice Address - Phone:706-315-8955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-13
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5054C1041C0700X
GACSW0082141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty