Provider Demographics
NPI:1790593598
Name:LEACH, TABETHA (CADC)
Entity type:Individual
Prefix:
First Name:TABETHA
Middle Name:
Last Name:LEACH
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04073-3322
Mailing Address - Country:US
Mailing Address - Phone:207-459-8331
Mailing Address - Fax:
Practice Address - Street 1:14 WINTER ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-3322
Practice Address - Country:US
Practice Address - Phone:207-324-4054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-26
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC7090101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)