Healthcare Provider Details

I. General information

NPI: 1528784238
Provider Name (Legal Business Name): DANIELLE LEACH LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2022
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 SE RIVERSIDE DR
STUART FL
34994-2584
US

IV. Provider business mailing address

1452 SE TIDEWATER PL
STUART FL
34997-5597
US

V. Phone/Fax

Practice location:
  • Phone: 631-972-4553
  • Fax:
Mailing address:
  • Phone: 631-972-4553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH20063
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: