=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053469635
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY KRISTINE LEFFEL L.C.S.W.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 322 E MAIN ST
-----------------------------------------------------
City | WILMORE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40390-1324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-396-1179
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 25
-----------------------------------------------------
City | WILMORE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40390-0025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-396-1179
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | KY 1622
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------