Healthcare Provider Details

I. General information

NPI: 1609473750
Provider Name (Legal Business Name): ASIA VIANNA MACK LEAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2020
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

529 14TH ST NW
WASHINGTON DC
20045-1000
US

IV. Provider business mailing address

94 WEBSTER ST NE APT 2
WASHINGTON DC
20011-4961
US

V. Phone/Fax

Practice location:
  • Phone: 202-986-5941
  • Fax:
Mailing address:
  • Phone: 404-934-5214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP9539
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGPC00541
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: