Healthcare Provider Details

I. General information

NPI: 1376244509
Provider Name (Legal Business Name): DIANNE LEACH LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2023
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 FAIRFIELD ST
SAINT ALBANS VT
05478-1743
US

IV. Provider business mailing address

102 S WINOOSKI AVE
BURLINGTON VT
05401-7406
US

V. Phone/Fax

Practice location:
  • Phone: 802-488-6000
  • Fax: 802-488-6919
Mailing address:
  • Phone: 802-488-6934
  • Fax: 802-488-6919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number151.0134164
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: