Healthcare Provider Details

I. General information

NPI: 1720493810
Provider Name (Legal Business Name): LEISIA KRISTINA LANDERS MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2014
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5966 SCOTTSVILLE RD
BOWLING GREEN KY
42104-0387
US

IV. Provider business mailing address

127 E WHITE OAK ST STE B
LEITCHFIELD KY
42754-1466
US

V. Phone/Fax

Practice location:
  • Phone: 270-904-5104
  • Fax: 270-201-5980
Mailing address:
  • Phone: 270-904-5104
  • Fax: 270-201-5980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6740
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number255423
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: