=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245424191
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEIGH CHURCH LADC,CPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2007
-----------------------------------------------------
Last Update Date | 02/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 325 E LIBERTY ST
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89501-2212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-322-6604
-----------------------------------------------------
Fax | 775-828-9815
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 325 E LIBERTY ST
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89501-2212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-322-6604
-----------------------------------------------------
Fax | 775-828-9815
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 514-L
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | CP0055
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------