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NPI Code Detail

MEDICARE: SHANE LEACH LCSW

MEDICARE: SHANE LEACH LCSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker12713-123WI

General Provider Information

NPI Number : 1861332827
Entity Type Code : Individual
Provider Name (Legal Business Name) : SHANE LEACH LCSW
Provider Business Mailing Address
First Line : 5555 N PORT WASHINGTON RD STE 200
Second Line :
City : GLENDALE
State : WI
Zip : 53217-4927
Country : US
Telephone Number : 262-999-3495
Fax Number : 262-821-6180
Provider Business Practice Location Address
First Line : 5555 N PORT WASHINGTON RD STE 200
Second Line :
City : GLENDALE
State : WI
Zip : 53217-4927
Country : US
Telephone Number : 262-999-3495
Fax Number : 262-821-6180
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/30/2026
Last Update Date : 05/05/2026

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