Basic Information
| Provider Information | |||||||||
| NPI: | 1437237831 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEAK | ||||||||
| FirstName: | LATASHA | ||||||||
| MiddleName: | TAMEKIA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FAMILY ADVOCATE | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEAK | ||||||||
| OtherFirstName: | TASHA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2336 GODDARD PARKWAY | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103346961 | ||||||||
| FaxNumber: | 4103346960 | ||||||||
| Practice Location | |||||||||
| Address1: | 114 N WASHINGTON ST | ||||||||
| Address2: | STE 30 | ||||||||
| City: | EASTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108225007 | ||||||||
| FaxNumber: | 4108225569 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | R968 | 01 | CAREFIRST FEDERAL GROUP | OTHER | LM49EA | 01 | MD | CAREFIRST BCBS GROUP | OTHER | 517251 | 01 | UHC MAMSI GROUP# | OTHER |