Healthcare Provider Details

I. General information

NPI: 1447530589
Provider Name (Legal Business Name): GLORIA L. LEAK MS, LPC, LCAS, CRC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2011
Last Update Date: 08/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 LYNNDALE CT STE C
GREENVILLE NC
27858-5462
US

IV. Provider business mailing address

2754 ANGE ST
WINTERVILLE NC
28590-7913
US

V. Phone/Fax

Practice location:
  • Phone: 252-752-8602
  • Fax:
Mailing address:
  • Phone: 919-221-4158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1575
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number8346
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: