Basic Information
| Provider Information | |||||||||
| NPI: | 1366187676 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | LEACHA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | ASW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4380 BASTILLE WALK | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958342122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2096871754 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4001 CA-104 | ||||||||
| Address2: | |||||||||
| City: | IONE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092744911 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2022 | ||||||||
| LastUpdateDate: | 05/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 106588 | CA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.