Provider Demographics
NPI:1780943290
Name:LEACH, MELISSA RENEE
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:RENEE
Last Name:LEACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:LEACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1080
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-864-1472
Mailing Address - Fax:270-864-1693
Practice Address - Street 1:1 MUSTANG TRAIL
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:KY
Practice Address - Zip Code:40342-1576
Practice Address - Country:US
Practice Address - Phone:844-435-0900
Practice Address - Fax:270-858-4029
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-04
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
KY173986101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30610026Medicaid