Healthcare Provider Details

I. General information

NPI: 1780943290
Provider Name (Legal Business Name): MELISSA RENEE LEACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MELISSA LEACH

II. Dates (important events)

Enumeration Date: 05/04/2012
Last Update Date: 12/08/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MUSTANG TRAIL
LAWRENCEBURG KY
40342-1576
US

IV. Provider business mailing address

PO BOX 1080
BURKESVILLE KY
42717-1080
US

V. Phone/Fax

Practice location:
  • Phone: 844-435-0900
  • Fax: 270-858-4029
Mailing address:
  • Phone: 270-864-1472
  • Fax: 270-864-1693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number173986
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: