Provider Demographics
NPI:1447530589
Name:LEAK, GLORIA L (MS, LPC, LCAS, CRC)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:L
Last Name:LEAK
Suffix:
Gender:F
Credentials:MS, LPC, LCAS, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2754 ANGE ST
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-7913
Mailing Address - Country:US
Mailing Address - Phone:919-221-4158
Mailing Address - Fax:
Practice Address - Street 1:620 LYNNDALE CT STE C
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5462
Practice Address - Country:US
Practice Address - Phone:252-752-8602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-21
Last Update Date:2011-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1575101YA0400X
NC8346101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)