Healthcare Provider Details

I. General information

NPI: 1205745973
Provider Name (Legal Business Name): KIMBERLY LEAKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2026
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 CHATEAU BLVD STE 507
KENNER LA
70065-2734
US

IV. Provider business mailing address

3129 PHOENIX ST APT B
KENNER LA
70065-5123
US

V. Phone/Fax

Practice location:
  • Phone: 504-358-8805
  • Fax:
Mailing address:
  • Phone: 504-339-1611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberLA10390
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: