Healthcare Provider Details

I. General information

NPI: 1720656630
Provider Name (Legal Business Name): CHIANTI SHANTEL LEAK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 SAM NEWELL RD STE 100
MATTHEWS NC
28105-7593
US

IV. Provider business mailing address

5820 E W T HARRIS BLVD STE 205
CHARLOTTE NC
28215-4032
US

V. Phone/Fax

Practice location:
  • Phone: 704-360-3637
  • Fax:
Mailing address:
  • Phone: 704-469-1243
  • Fax: 704-469-1713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number28735
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC019867
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: