Healthcare Provider Details

I. General information

NPI: 1053903484
Provider Name (Legal Business Name): MACKENZIE LEACHMAN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2021
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2412 GREATSTONE PT
LEXINGTON KY
40504-3274
US

IV. Provider business mailing address

2412 GREATSTONE PT
LEXINGTON KY
40504-3274
US

V. Phone/Fax

Practice location:
  • Phone: 859-224-4081
  • Fax: 859-224-4082
Mailing address:
  • Phone: 859-224-4081
  • Fax: 859-224-4082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number129937
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: