=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447530589
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GLORIA L. LEAK MS, LPC, LCAS, CRC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2011
-----------------------------------------------------
Last Update Date | 08/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 620 LYNNDALE CT STE C
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27858-5462
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-752-8602
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2754 ANGE ST
-----------------------------------------------------
City | WINTERVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28590-7913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-221-4158
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 1575
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 8346
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------