Healthcare Provider Details

I. General information

NPI: 1013829696
Provider Name (Legal Business Name): LEAH MICHELLE FORNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2026
Last Update Date: 09/19/2026
Certification Date: 09/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2017 BUNCHE DR NW
ROANOKE VA
24012-4601
US

IV. Provider business mailing address

2017 BUNCHE DR NW
ROANOKE VA
24012-4601
US

V. Phone/Fax

Practice location:
  • Phone: 240-776-5647
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0730000847
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: