Basic Information
| Provider Information | |||||||||
| NPI: | 1336694520 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEACH | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | ALLAN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSWA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 284 EXECUTIVE PARK DR | ||||||||
| Address2: | STE 100 | ||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280251833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049391100 | ||||||||
| FaxNumber: | 7049391173 | ||||||||
| Practice Location | |||||||||
| Address1: | 1190 W ROOSEVELT BLVD | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281102818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042966200 | ||||||||
| FaxNumber: | 7042964668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2016 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | P010571 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1336694520 | 05 | NC | MEDICAID | 19NG5 | 01 | NC | BCBS | OTHER |