Healthcare Provider Details

I. General information

NPI: 1871171843
Provider Name (Legal Business Name): MICHAEL LEIPOLD SR. COUNSELOR TRAINEE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 N DETROIT ST
XENIA OH
45385-2909
US

IV. Provider business mailing address

3103 DIXIE HWY
HAMILTON OH
45015-1653
US

V. Phone/Fax

Practice location:
  • Phone: 513-892-4673
  • Fax: 513-737-1107
Mailing address:
  • Phone: 513-892-4673
  • Fax: 513-737-1107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2103126
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2103126
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: