Healthcare Provider Details

I. General information

NPI: 1477606507
Provider Name (Legal Business Name): MARYELLEN F LEIGH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 NORTHWEST DR
PLAINVILLE CT
06062-1534
US

IV. Provider business mailing address

234 BRENTWOOD DR
WALLINGFORD CT
06492-4353
US

V. Phone/Fax

Practice location:
  • Phone: 860-747-8719
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number005700
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: