=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255714523
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROLYN LEACH M.A.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2015
-----------------------------------------------------
Last Update Date | 06/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7030 N OAKLEY AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60645-3408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-769-3313
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7030 N OAKLEY AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60645-3408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-769-3313
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180012870
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------