Healthcare Provider Details

I. General information

NPI: 1053469635
Provider Name (Legal Business Name): MARY KRISTINE LEFFEL L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 E MAIN ST
WILMORE KY
40390-1324
US

IV. Provider business mailing address

PO BOX 25
WILMORE KY
40390-0025
US

V. Phone/Fax

Practice location:
  • Phone: 859-396-1179
  • Fax:
Mailing address:
  • Phone: 859-396-1179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberKY 1622
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: