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General NPI Number Information
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NPI Number | 1619294634
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Entity Type | Organization
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Legal Business Name | EDA LEACH
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Dates
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Enumeration Date | 04/29/2010
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Last Update Date | 04/29/2010
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Provider Practice Location Address
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Address Line | 1746 DEN HERTOG ST SW
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City | WYOMING
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State | MI
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Zip | 49519-3337
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Country | US
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Telephone | 616-531-1142
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Fax | 616-531-1142
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Provider Business Mailing Address
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Address Line | 1746 DEN HERTOG ST SW
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City | WYOMING
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State | MI
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Zip | 49519-3337
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Country | US
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Telephone | 616-531-1142
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Fax | 616-531-1142
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Authorized Official
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Title or Position | SOCIAL WORKER
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Name | MS. EDA MONICA LEACH
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Credential | LMSW
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Telephone | 616-531-1142
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 638107811
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | 638107811
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | 638107811
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License Number State | MI
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