Provider Demographics
NPI:1720349004
Name:LEINBACH, MARK (LISW-S)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:LEINBACH
Suffix:
Gender:M
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15550 DURSTINE RD
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:OH
Mailing Address - Zip Code:44624-9428
Mailing Address - Country:US
Mailing Address - Phone:330-359-6100
Mailing Address - Fax:330-319-7381
Practice Address - Street 1:15550 DURSTINE RD
Practice Address - Street 2:
Practice Address - City:DUNDEE
Practice Address - State:OH
Practice Address - Zip Code:44624-9428
Practice Address - Country:US
Practice Address - Phone:330-359-6100
Practice Address - Fax:330-319-7381
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI08000841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHI0800084OtherSUPERVISING INDEPENDANT SOCIAL WORKER LICENSE