=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942772074
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON T LEACH BA CMS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/31/2018
-----------------------------------------------------
Last Update Date | 12/31/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4835 POPLAR LEVEL RD STE 110
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40213-2906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-443-5273
-----------------------------------------------------
Fax | 502-631-9660
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11110 LITTLE SPRING BLVD
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40291-5066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-712-8905
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------