Provider Demographics
NPI:1700990884
Name:LEAKE, DONALD A (BA MA LSW)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:A
Last Name:LEAKE
Suffix:
Gender:M
Credentials:BA MA LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:OH
Mailing Address - Zip Code:44857-1899
Mailing Address - Country:US
Mailing Address - Phone:419-668-7628
Mailing Address - Fax:
Practice Address - Street 1:3690 ORANGE PL
Practice Address - Street 2:SUITE 220
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4464
Practice Address - Country:US
Practice Address - Phone:216-831-1494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1041C0700X 5.0031124101YM0800X, 103TB0200X, 103TC1900X, 103T00000X, 103TP2701X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical