Healthcare Provider Details

I. General information

NPI: 1265067581
Provider Name (Legal Business Name): NATHAN LEACH LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2020
Last Update Date: 06/14/2025
Certification Date: 06/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N PASEO DE ONATE
ESPANOLA NM
87532-2683
US

IV. Provider business mailing address

5 SE 69TH AVE
PORTLAND OR
97215-1336
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-6158
  • Fax:
Mailing address:
  • Phone: 623-308-2472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2025-0335
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: