Basic Information
| Provider Information | |||||||||
| NPI: | 1568546422 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEACH | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20800 CENTER RIDGE RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | ROCKY RIVER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441164312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403334949 | ||||||||
| FaxNumber: | 4403335044 | ||||||||
| Practice Location | |||||||||
| Address1: | 20800 CENTER RIDGE RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | ROCKY RIVER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441164312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403334949 | ||||||||
| FaxNumber: | 4403335044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 03/18/2009 | ||||||||
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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 | 103TC0700X | 2671 | OH | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0355057 | 05 | OH | MEDICAID |