=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043656127
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CYNTHIA ELIZABETH LEACH MSW, LCSW, LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2013
-----------------------------------------------------
Last Update Date | 05/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 390 AMWELL RD BLDG 3 SUITE NUMBER 312
-----------------------------------------------------
City | HILLSBOROUGH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08844-1225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-610-5011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 PINEKNOLL DR
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08648-3138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-610-5011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 051884-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 44SC05427500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW5574
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 37F100169200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------